The internet's only blog on Health Insurance

August 06, 2009

California Offers Lessons on Insurance Exchanges

As Congress debates creating insurance "exchanges" as part of a health-care overhaul, the failure of a similar effort in California may offer important insights, former participants in the program say.

From 1993 to 2006, small businesses in California could buy health insurance through an exchange run initially by the government, and later by a nonprofit group.

The plan was undermined when some businesses with relatively healthy workers bought policies more cheaply directly from insurers, bypassing the exchange. That left the exchange with a shrinking pool of less-healthy workers, forcing rates higher and prompting many insurers to withdraw. Managers chose to shut the program in 2006 when one of three remaining insurers withdrew.

"There are definite lessons to be learned," said John Ramey, who as former head of the Managed Risk Medical Insurance Board helped implement California's exchange. "We learned them the hard way out here."

Among those lessons, he and others said: Employers and individuals who qualify must be required to obtain health insurance through the exchange. Failing that, John Grgurina, who ran California's exchange from 2002 until it ended, said government must impose rules governing rates and eligibility to protect the exchange from attracting a disproportionate share of high-risk people.

An exchange aims to get better prices for coverage by banding together businesses and individuals. Insurers would have an incentive to join an exchange because they would gain access to more potential customers. Individuals and employees of businesses that participate in an exchange would be able to chose from the available plans and pay the same rate.

Exchanges, either on a regional basis or a single national one, are likely to be a part of any final health-care legislation. Late Friday, the House Energy and Commerce Committee approved its health-care bill, though a full House vote won't come until the fall.

President Barack Obama on Saturday praised the House committee's action and urged lawmakers to "build upon the historic consensus."

The compromise proposal agreed to in the House Friday exempted more businesses from the mandate to provide coverage to their employees and offered subsidies to fewer individuals to buy insurance through an exchange, which would shrink the number of potential participants.

Each of the three major bills -- one in the House and two in the Senate -- would create one or more exchanges. The specifics vary, but most of the proposals would impose more regulations than the failed California program, which analysts say would help the exchanges compete.

Despite California's struggles, insurance exchanges are still the most effective way to expand coverage, said Elliot Wicks, a health-care consultant who wrote a report on the California program. The report, released last month, was commissioned by the California HealthCare Foundation, a private independent nonprofit.

Veterans of the California effort said the ultimate effectiveness of any exchange would rest on details that have yet to be worked out. They said the pool of people in an exchange should be as broad as possible, to spread both risk and administrative costs.

December 02, 2008

Why is single-payer health reform not viable?

When it comes to health care reform in America, there is a relatively simple solution that will cover everyone's basic health care, control costs and save businesses, most people and the country a lot of money.

It's called a single-payer health plan, where the government collects taxes to finance national health insurance. The government, which is the "single payer," covers all citizens and pays the bills when they visit private (or public) doctors, hospitals and other facilities for medical care.

All would have basic coverage, regardless of whether they have a job, or where they work. Nobody gets billed for basic care. No-body goes broke because of medical bills.

Yet this option has been declared "off the table" by Sen. Max Baucus, D-Mont., who's among those leading the charge for health care reform in America.

Top Democrats who will be deciding policy in America in 2009, including Baucus and President-elect Barack Obama, say single-payer is "not politically feasible," because the public won't strongly support it.

What they really mean is that when it comes to health care reform, they don't want a political fight with some of the nation's most powerful financial interests, which have the resources and the motivation to turn public opinion against meaningful reforms.

These interests include the health insurance industry, pharmaceutical drug companies, some hospitals, highly paid medical specialists, medical suppliers and others who now profit handsomely from our current system - and who could no longer command those profits under a single-payer system or an alternative form of a national health plan.

November 26, 2008

1.3 million Cal kids lack health insurance

The nation has 8.6 million children who lack public or private health insurance and 1.3 million of them are in California, Families USA, a Washington-based advocate for expanded health access, says in a report based on new census data.

California, the nation's most populous state, is just behind Texas in the numbered of medically uninsured children, Families USA says, and at 12.5 percent has the nation's 12th highest rate. Texas is No. 1 at 20.5 percent.

Families USA, confirming previous reports, says that 88.2 percent of uninsured children come from families with at least one working adult. Families without earned income usually qualify for one of the public medical plans such as Medi-Cal. It's been estimated that more than 6 million of the state's 38 million residents lack health insurance.

Last year, Gov. Arnold Schwarzenegger tried and failed to gain legislative approval of a plan to cover virtually all of California's uninsured residents. The full Families USA report is available here.

November 24, 2008

Sudden health-care changes unlikely in California

Given all Barack Obama said about change during the presidential race, he might be expected to quickly revamp America's health-care system, which virtually everyone calls a mess.

Local people who have pushed for health-care reform say, however, they don't expect major changes in a hurry. But they do foresee the new president attending to the issue.

Tatiana Fassieux, manager of the Chico-based Health Improvement Counseling and Advocacy Program (HICAP), which advises Medicare beneficiaries on their California health care coverage, recalled attending a conference last year where the next president spoke.

"Obama did talk about the benefits of a single-payer system," she said. However, with the nation's economic problems taking center stage, "I don't see any changes happening immediately," she added.

In a single-payer system, competition among insurance companies is eliminated, and one agency is put in charge of administering health coverage and paying providers.

For years, a local group, the Butte County Healthcare Coalition, has promoted a single-payer system for California and the nation. Several of its members told the Enterprise-Record they expect incremental changes from Obama. That doesn't thrill them because they believe single payer is the only real fix for what ails America's health-care system.

"We do think President Obama will do more than has been done so far," said Jeanne Ertle of Chico. She is a member of the local coalition and also vice-chairwoman of a statewide group, Health Care for All — California, which promotes single payer.

The term "universal health care" can have different meanings, she said. To some people, it just means everyone has health insurance of some sort. What it should mean, she said, is that everyone has access to the care they need. She's convinced single-payer is the only way to achieve that, she said.

Norma Wilcox, treasurer of the local coalition, said she's read Obama's health-care plan, which she described as "cautious." He proposed requiring parents to buy health care coverage for their children and said he hoped to cover two-thirds of those who now have no insurance.

"I think he's open to input and is testing the waters," Wilcox said.

Congressman Wally Herger, R-Chico, said in a phone interview from Washington that single payer has gotten lots of discussion in the House but that no plan has materialized.

November 19, 2008

California farmers, ranchers struggle over health care costs

California’s farmers and ranchers are struggling with health care bills that, in some instances, threaten the viability of their family businesses, according to a report Wednesday by the Access Project and funded by the California Endowment.

The report finds that while almost all farm and ranch operators have health insurance, one in five says that California insurance premiums and other out-of-pocket health care costs are causing financial difficulties for themselves and their families.

These families report spending 37 percent of their income on health care coverage and medical costs.

“A better term for health insurance that leaves nearly one in five purchasers in financial jeopardy might be called ‘product failure’,” says Carol Pryor, a report author and policy director for the Access Project.

The survey also found that more than three in 10 farmers and ranchers (31 percent) are spending at least 10 percent of their annual income on health insurance premiums, prescriptions and other out-of-pocket medical costs. Spending this much on health care is a commonly used indicator of financially burdensome health care costs, the report’s authors say.

Farm and ranch operators are especially hard hit because they are often forced to buy insurance on the individual, non-group market, where insurance generally costs more and covers less, says the report.

The study shows that on average, those farmers and ranchers purchasing insurance in the non-group market spent almost twice as much on health care as those who got their health care coverage through off-farm or off-ranch employment. The median amount spent by farmers and ranchers who got insurance on the non-group market was $8,500 a year (including premiums and out-of-pocket costs), compared to $4,630 spent by people who got insurance through employment off the farm or ranch.

Three in 10 of the study’s respondents purchased health coverage directly on the open market. Nationally, only 8 percent of Americans obtain their health insurance this way.

“Right now farmers are faced with increasing costs for everything – fuel, feed, fertilizer. Adding exorbitant health care costs on top of these expenses is simply not sustainable and threatens the viability of family farm operations,” says Lynn McBride, director of the California Farmer’s Union.

One-fourth of those surveyed (26 percent) report having to draw on other financial resources to cover the costs of care. Of these respondents, 70 percent dipped into family savings and nearly one in three (29 percent) incurred credit card debt or increased existing debt. Others took out a loan, borrowed against their farm, withdrew money from a retirement account or turned to friends and family for help.

October 30, 2008

Grim Health Picture For California's Low-income Kids

There are some positives - the number of overweight children in California declined slightly and preschool enrollment increased. Yet the overall health picture, especially for California's low-income kids, is grim according to a new research brief "Trends in the Health of Young Children in California" by the UCLA Center for Health Policy Research and sponsored by First 5 California.

The brief found that two-thirds of California children are without health insurance are from low-income families. Low-income children utilize community clinics for primary care at three times the rate of higher income children. And the proportion of children enrolled in private health insurance is shrinking - while the reliance on public programs is growing.

"The research suggests there has been a steady erosion of health care and health access for the most vulnerable children," said David Grant, lead author of the policy research brief and director of the California Health Interview Survey (CHIS). "As Californians, we have a lot of work to do to reverse the trend."

The research brief examined trends in health among Californian children from a wide range of ethnicities and economic backgrounds. It is based upon an analysis of data collected by CHIS, the nation's largest state health survey, in 2001, 2003 and 2005. Conducted by the UCLA Center for Health Policy Research, CHIS surveys up to 50,000 Californians - including up to 10,000 children - every two years.

"There is no higher priority than the health and well-being of our children," said Kris Perry, executive director of First 5 California. "This research brief provides a valuable reminder of where our priorities must be, even at a time of scarce resources."

Fewer overweight children: The prevalence of overweight children ages 0-5 dropped slightly in California from 14% in 2001 to 12% in 2005. There were steep drops in Riverside County (16.2% in 2003 to 12.4% in 2005) and San Bernardino County (16.2% in 2003 to 8.4% in 2005). Los Angeles County also dropped (14.3% in 2003 to 12.8% in 2005) as well as Alameda County (13.4% in 2003 to 8.9% in 2005) and San Diego County (12.9% in 2003 to 8.5% in 2005).

No improvement in health insurance coverage: The proportion of children ages 0-5 in California who lacked health insurance for all or part of the previous year - one in ten children - remained unchanged between 2001 and 2005.

October 05, 2008

California Health Coverage Costs are a Bit Lower

Cost increases for California health insurance premiums are lower this year, and although California’s are higher than some other states, they are also still lower than in previous years.

The Kaiser Family Foundation and Health Research and Educational Trust confirm what news wires also are reporting: nationally, the rise in cost of health care premiums is about 5 percent. This continues a trend from 2007, when a similar small cost increase was instituted.

However, according to Randy Jones of Hometown Insurance Services in Solvang, in California premiums are somewhat higher: “Ours in California, the rate went up higher than that. We’re getting a 10 percent rise,” he said.

Although the national increases were reported at the end of September, California’s current insurance rates are more difficult to come by. Insurance industry and regulatory agency figures found on the Internet indicate the 10 percent rise is in the ballpark.

“If increases aren’t as bad this year, they were pretty horrendous last year,” Jones continued. One reason California’s premiums are not shooting up, he said: “We’re healthier.”

Another reason that California’s health insurance premiums have stayed relatively low, according to Jones, is the result of a ballot measure from about 15 years ago. That measure was approved by voters, capping punitive damage amounts. “So insurance companies don’t have to approve every little thing for fear of being sued,” Jones said. “But the quality of California health care hasn’t changed.”

The Kaiser study showed that not only insurance premiums have shown a steady increase. “Cost sharing for medical services has also increased in recent years. The percentage of employers sponsoring insurance and the percentage of workers covered by employer-sponsored insurance remained stable over the past year.”

September 16, 2008

California Legislature Drops Some Health Cuts From Budget

Early this morning, the California Legislature approved a budget proposal for fiscal year 2008-2009 that avoided some cuts to health care and other programs, the San Jose Mercury News reports. Democrats widely opposed the proposed cuts (Zapler, San Jose Mercury News, 9/16).

The proposal does not eliminate dental services for adult Medi-Cal beneficiaries or impose new restrictions on Medi-Cal services for undocumented immigrants. Medi-Cal is California's Medicaid program (Halper/Rau, Los Angeles Times, 9/16).

Beyond those already introduced by Senate Democrats, the budget agreement does not include cuts to California health care, human services or education programs, according to information Ventura County officials received from the California State Association of Counties (Biasotti, Ventura County Star, 9/16).
Healthy Families, Medi-Cal

The proposal would restore most of the 10% cut in Medi-Cal payments to health care providers beginning in March 2009 (Lin, AP/San Francisco Chronicle, 9/16). California's Medicaid reimbursement rates will remain the lowest in the U.S. even after the cuts are restored, according to the Los Angeles Times.

September 04, 2008

California Children at Risk of Losing Health Insurance Coverage

Thousands of California children could lose health insurance coverage in the coming months as a result of changes in Medi-Cal rules and decreased funding for local efforts that have provided coverage to children, the Los Angeles Times reports. Medi-Cal is California's Medicaid program.

State lawmakers will require parents of children enrolled in Medi-Cal to renew their enrollment every six months.

The administration of Gov. Arnold Schwarzenegger (R) projects that the requirement will contribute to a drop in Medi-Cal enrollment over the next two years of about 196,000 children.

As a result, the state estimates that the parents of 19,000 children no longer will receive coverage through the program by July 2009.

The changes to Medi-Cal and Healthy Families were approved as part of a larger effort to address the state budget deficit.
Local Efforts.

Beyond changes to Medi-Cal and Healthy Families rules, children also could lose coverage because of funding challenges faced by local initiatives operating in 30 counties. The efforts target children who are ineligible for Medi-Cal or Healthy Families because of income or citizenship requirements.

The initiatives are funded largely by private philanthropies and local First 5 commissions, which disburse funds from a state tobacco tax for early childhood health care and education efforts.

Wendy Lazarus, co-president of the advocacy group Children's Partnership, estimates that enrollment in the efforts has dropped by 8,000 over the past two years.

August 13, 2008

California health insurance ambition narrows

Seeking to salvage two years of efforts to completely remake California's health insurance system, Gov. Arnold Schwarzenegger and Democratic legislators are nearing deals intended to rein in costly, meager medical insurance policies sold directly to individuals.

In the final weeks of the legislative session, they are negotiating measures that would limit insurer profits on California individual insurance plans, require plans to provide a minimum set of benefits and restrict insurers' ability to cancel policies retroactively.

The new focus reflects how far Schwarzenegger remains from his original healthcare goal: to orchestrate medical insurance for the 5 million Californians who lack it. Despite a year of strenuous campaigning for his vision, which garnered attention nationwide, the state Senate rejected that $14.9-billion plan in January.

Many of the concepts now under discussion were included in that proposal. Although most California insurers supported the governor's broader effort because it would have created millions of new customers, the industry is uniformly resisting the current push to circumscribe some of its most lucrative products.

Three million Californians buy health insurance on their own rather than through employers. Insurers keep health insurance premiums low -- and profits high, their critics say -- on some individual policies by limiting the services they cover. Such plans may exclude prescription drugs and maternity services, for example; others may cover only hospital visits.

Many of the policies have big deductibles and require patients to pay large portions of their expenses, costing them much more than coverage obtained at workplaces.

July 30, 2008

California Governor Signs Health Care Protection Bill

California Governor Arnold Schwarzenegger signed AB 1150 by Assemblymember Ted Lieu (D-Torrance) which bans health insurance companies from rewarding their employees for canceling or limiting a patient's health insurance. While the Governor signed AB 1150 because of the urgent need to protect consumers from unfair health care rescissions, he continues to believe that health care reform must be comprehensive.

To that end, he has proposed legislation that would be the building blocks of comprehensive health care reform and is working with the legislature on a joint solution that will protect consumers, control costs and promote prevention.

"Until we achieve comprehensive health care reform, stopping unfair health care rescissions is an urgently needed consumer protection," Governor Schwarzenegger said. "This terrible practice further illustrates the erosion of the California health care system and the need for comprehensive health care reform. Today we are standing up for consumers by putting an end to a deplorable practice, and I will continue working with my partners in the legislature to stop unfair health care rescissions once and for all."

The Governor's goal of comprehensive health care reform would make health care rescissions a problem of the past. The Governor's AB x1 1, the Health Care Security and Reduction Act, would have required that all Californians take responsibility for their health coverage while guaranteeing that no Californian is turned away from buying Calfiornia health insurance based on their age or medical history.

July 18, 2008

Insurance Cancellation Questions Could Spread Beyond California

Today’s Health Blog jargon of the day is rescission, the California insurance industry’s practice of revoking individual insurance policies because of health-related mistakes or omissions on the application for coverage.

The companies say this is a key step for fighting fraud, but they’ve come under criticism in California by those who accuse them of going over applications with a fine-tooth comb after members who’ve been enrolled for a while get sick or injured and start submitting claims.

Now it looks like the push-back against rescission may be spreading. Henry Waxman, a Democratic California Congressman, held a hearing on the subject yesterday and said his oversight committee plans to investigate the issue nationally.

“I understand that California insurance companies need to protect themselves from fraud,” Waxman said in his opening statement. But “insurers are using technicalities or trumped-up ‘misrepresentations’ to rescind policies after individuals get sick and accumulate hundreds of thousands of dollars in medical bills.”

The health insurance industry supports third-party review, established by the states, for rescission decisions, Stephanie Kanwit, special counsel to the trade group America’s Health Insurance Plans, said at yesterday’s hearing.

Kanwit said the practice is very rare. And, she said, collecting accurate information on applicants’ health history is essential for the insurance market to function. “When individuals wait until they are ill before purchasing health insurance, costs are increased for other policyholders who pay into the system on a regular basis,” she said.

Meanwhile, back in California, the industry’s rescission problems are rolling on. The state’s Anthem Blue Cross and Blue Shield yesterday agreed to pay the state $13 million in fines and to offer new coverage to more than 2,200 Californians the companies dropped after they became ill, the Los Angeles Times reports. As part of the agreement the companies didn’t admit wrongdoing.

And earlier this week, Los Angeles’ city attorney announced a lawsuit against Blue Shield over the rescission issue. The city attorney launched an investigation into the issue earlier this year, and has already filed lawsuits against a few other insurers.

Thus, nearly 64 percent of uncompensated care comes from those insured by government, not the uninsured. Physicians also fare badly under said government and private insurance programs.

There is not one nationwide or statewide price for services. Supposedly higher cost-of-living counties get higher rates, but this isn't true for Santa Barbara and San Luis Obispo counties, which are grouped in the cheapest rates paid in California.

As for a health-care crisis, expect it to be severe in Lompoc. Several primary-care physicians have left or are contracted to leave Lompoc shortly.

It is time for the citizens of the Lompoc Valley to realize they face a local health-care crisis, one that government health care in California does much to cause. Our local hospital suffers from HMOs routinely referring specialist examinations and elective in- and out-patient hospital services to Santa Barbara, about 65 miles away, while, by law, HMOs must offer care within 30 miles. HMO patients can insist on their right to be cared for locally when appropriate health care service is available.

July 06, 2008

Private health insurance companies regulated by the Department of Managed Health Care (DMHC) spend $6 billion each year on administration, and divert an additional $4.3 billion to profit, according to a report released by the California Medical Association (CMA). Prepared using data obtained under the Knox Keene Act, the report breaks down how private health insurance companies spend their revenues.

"This report paints in stark terms why California health care costs are skyrocketing for Californians," said Dr. Richard Frankenstein, M.D., President of CMA. "Health insurance companies in California spend billions of California's health care dollars each year on administration, and for-profit insurers divert billions of dollars more to profit. Californians' health care dollars should be spent on health care, not on bureaucracy."

Currently, private health insurance companies regulated under Knox Keene - representing some 60% of the health insurance market - are required to spend no more than 15% of their revenues on administrative costs. CMA and other health care advocates believe the statute includes profits as administrative costs; health insurance companies exclude profits from the 15%, allowing them to spend as little as they want on actual health care. SB 1440, a bill authored by Senator Sheila Kuehl and sponsored by CMA, would require insurance companies to spend 85% of their revenues on health care, driving down health care costs for consumers and potentially making coverage more affordable.

"It's not acceptable for us to ignore such massive waste in the insurance industry when Californians are being bankrupted by rising health insurance premiums and gutted benefits," stated Senator Kuehl. "California consumers have a right to know that there is a basic formula in the law for how much of their money is actually being spent on medical care. This is the least we should be doing."

July 01, 2008

Californians Not Getting the Health Care They Need

Call them stoic, call them cost-conscious, call them under- or uninsured...but almost 20 percent of the U.S. population either went without or delayed needed medical care at sometime during 2007. That figure is up from 14 percent in 2003, and if you are counting, is an additional 9.5 million Americans who didn't get the medical care they needed in 2007.

People had numerous reasons why they had postponed or had completely forgone medical care for themselves during the year. Chief among them was out-of-pocket medical costs and deductibles they couldn't afford to pay, followed by a list that included things like a lack of acceptable clinic hours of operation, difficulty getting to clinics during working hours, problems with doctors being overbooked that resulted in difficulty getting timely appointments, and doctors and hospitals not accepting their insurance plans.

It wasn't just people without medical insurance that were avoiding medical visits, but both people with and without insurance that were either delaying or forgoing medical care, according to a random national phone survey. The survey was conducted by the Center for Studying Health System Change, a nonpartisan policy group, who called 18,000 people, with a 43 percent response rate.

The study's lead author, Peter Cunningham, noted that as health care costs increase, a larger share of cost, often in the form of higher deductibles, is being shifted to people and families, requiring them to pay more out of their own pockets. "To the extent that health insurance cost increases are passed on to individuals, continued declines in access to care are inevitable," wrote the co-authors of the study.

Karen Ignagni, chief executive of America's Health Insurance Plans, an insurance-industry trade group, feels that a variety of issues need to be addressed by policy makers to make surgery, medical imaging, and specialty drugs more affordable to the general public, and to standardize quality of care among providers. The cost of drugs and services has risen at a rate at least twice that of inflation for several years, making it more difficult for even those with health insurance to pay for medical care.

June 26, 2008

Private California health insurance companies regulated by the Department of Managed Health Care (DMHC) spend $6 billion each year on administration, and divert an additional $4.3 billion to profit, according to a report released by the California Medical Association (CMA). Prepared using data obtained under the Knox Keene Act, the report breaks down how private health insurance companies spend their revenues.

"This report paints in stark terms why health care costs are skyrocketing for Californians," said Dr. Richard Frankenstein, M.D., President of CMA. "Health insurance companies in California spend billions of California's health care dollars each year on administration, and for-profit insurers divert billions of dollars more to profit. Californians' health care dollars should be spent on health care, not on bureaucracy."

Currently, private health insurance companies regulated under Knox Keene - representing some 60% of the health insurance market - are required to spend no more than 15% of their revenues on administrative costs. CMA and other health care advocates believe the statute includes profits as administrative costs; health insurance companies exclude profits from the 15%, allowing them to spend as little as they want on actual health care. SB 1440, a bill authored by Senator Sheila Kuehl and sponsored by CMA, would require insurance companies to spend 85% of their revenues on health care, driving down health care costs for consumers and potentially making coverage more affordable.

"It's not acceptable for us to ignore such massive waste in the Californian insurance industry when Californians are being bankrupted by rising health insurance premiums and gutted benefits," stated Senator Kuehl. "California consumers have a right to know that there is a basic formula in the law for how much of their money is actually being spent on medical care. This is the least we should be doing."

If SB 1440 had been in effect in the last reporting year, HMOs would have spent $1.1 billion less on administrative costs and profit - money that would have gone instead to provide health care to their policyholders. Blue Cross policyholders alone would have benefitted from $700 million more in health care that instead went to administrative costs and profit.

It's 'buyer beware' in California individual health insurance market

Thwarted in their efforts to overhaul the state's health care system, consumer advocates are now concentrating their efforts instead on tightening regulation of that market.

Unlike the heavily regulated group insurance market, advocates say the California individual insurance market is rife with "junk insurance" policies that provide minimum benefits, such as hospital-only coverage, and don't set limits on out-of-pocket expenses.

Advocates say it's often impossible to determine what a plan does or doesn't cover, and some consumers – like Mary McCurnin and Ron Bednar of Rancho Cordova – find out too late after they run up thousands of dollars in medical costs.

California health plans would be split into five tiers to allow consumers to compare prices and better understand what they were buying.

"Consumers have the right to basic information about what they're buying," said Steinberg, D-Sacramento. "This bill is all about transparency, about ensuring that so-called junk insurance is no longer a part of the market."

SB 1522 is one of more than a dozen Democratic bills targeting the insurance industry that are moving through the Legislature.

Other bills would block insurers from canceling policies of patients needing costly care and would require insurers to spend at least 85 percent of their earnings on California medical care.

June 16, 2008

LAO Confirms California Single Payer Reduces Health Care Spending

This is my fifth essay for 2008. I interrupt my presentations on the current budget crisis to report on a confidential analysis of SB 840, my legislation creating a single payer health insurance system in California, requested by anonymous members of the Assembly [the requesters’ names are not revealed, as a matter of course, by the Legislative Analyst’s Office (LAO)] and conducted, in the middle of their budget analyses, by the California Legislative Analyst’s Office. My first 2008 essay was an update on the 2007 “year of California health reform”. The second set out some background information on actions taken by the legislature to re-balance the 2007-2008 budget given shrinking revenues. The third reviewed the Governor’s budget as he presented it in January of this year. This essay will analyze the LAO review of a single payer system for California.

Why the Legislative Analyst Looked at SB 840:

The LAO, in addition to their yearly on-going analysis of state spending and the budget, receives requests from members of the Legislature to look at the fiscal impacts on the state of various legislative measures. You may recall that during the discussion of the omnibus health measure put forward by the Governor and then-Speaker Fabian Nunez, Senate President pro-temps Don Perata asked the Legislative Analyst’s Office to report on the potential impact of the bill on State finances. In so doing, the LAO took into account a proposed funding initiative the Governor had submitted for the next ballot go-round which, if adopted by the people, would have set out a plan to fund the measure to be put on the ballot later in the year.

The LAO’s report was presented to the Senate Health Committee and the programmatic bill did not pass the Committee. The funding mechanism was not in front of the Committee and did not go on the ballot.

Following the defeat of that California insurance bill, three members asked the LAO to analyze SB 840, not only for its impact on State spending (which was found to be favorable), but also for the larger issues raised in funding the new program.

June 13, 2008

California Gets Failing Grade on Consumer Health Protections

Key health reform bills got a boost today with the unveiling of a national report that compared California to other states in terms of consumer protections for individual California health insurance.

Key health consumer advocates stated that insurance companies can deny health coverage to people with pre-existing conditions, refuse to pay for services needed to treat common ailments, and yank policies and deny payments when a consumer faces a rash of medical bills, and California (and other states) have little authority to protect consumers from such abuses.

Health Access California has based our comments today on a study published by Families USA, the national organization for health care consumers. Titled “Failing Grades,” the study reviews whether key protections are provided to healthy consumers to prevent insurance company abuses in California, as well as each of the other 49 states and the District of Columbia.

Without the purchasing power of group coverage, a Californian getting insurance as an individual is simply at the mercy of the big insurers, with few consumer protections. This report shows that California needs to tame our wild, wild west of an individual insurance market, and place new oversight over the insurance companies. This report places a spotlight on key bills pending in the California legislature, to ensure that coverage has value, and is there when the consumer needs it.

Bill up for key committee votes in the next few weeks will spotlight the need for significant new consumer protections, especially in the individual insurance market where consumers have little purchasing power and are simply at the mercy of big insurance companies.

THE STUDY:

The findings in the Families USA report show that consumers in most states are unprotected from many of these abuses.

• Only five states prohibit all California health insurance companies from cherry-picking the healthiest consumers and excluding everyone else. California allows for denying people for “pre-existing conditions,” even minor ones.

• In 35 states and the District of Columbia, there are no limits on how much insurers can increase premiums based on an individual’s health status. An additional six states have limits that still allow dramatic variations in premiums. California allows unwarranted increases in premiums.

June 11, 2008

California Health Insurance: Extreme Matrimony Edition

Some couples, straight and gay, are finagling wedding dates to quickly get both spouses on a company plan. Other married couples cruising for a breakup can at least agree on postponing divorce to keep both people on the existing California health plan of one of them. And some self-employed people are hiring workers just to qualify for group insurance, Dow Jones Newswires’ Victoria E. Knight reports.

The rub is basic. Under federal law, insurers have charge the same for premiums for everybody in an employer-sponsored insurance plan–no matter their health. But try buying health insurance on the open market, and you may face high prices or rejection, depending on your medical history.

One planner told Knight about a client, a woman in her mid-50s, who moved up her wedding so that her fiance, would also become eligible for health benefits offered to workers and spouses as part of a corporate buyout package at her job.

A business owner in California, covered under a small group insurance plan, put her husband on the payroll largely for insurance reasons. “I hired my husband to run my office and manage the IT,” the woman told Dow Jones, who asked not to be named for fear of drawing the attention of insurers.

Seven percent of Americans said that in the past year they or someone in their household decided to tie the knot mainly so one spouse would be eligible for the other’s California health coverage, according to a survey by the Kaiser Family Foundation. We were a little skeptical about the figure, which by our calculation seemed a bit high, but have little doubt that insurance worries weigh heavily on millions, married or otherwise.

June 05, 2008

Aetna Introduces Dental-Only Insurance Plans for Individuals and Their Families

Aetna (NYSE:AET) announced today that it has begun selling stand-alone dental plans to individuals and families, which are now effective as of June 1, 2008. These new products will initially be offered in Arizona, Delaware, Illinois and Pennsylvania, with plans to expand their availability to additional states in the future.

Individuals, including those who are eligible for Medicare, will be able to purchase these plans at any age. In addition, there will be no medical underwriting, meaning that individuals are automatically accepted if they apply (prices will vary based on age and geographic region).

There will be two PPO-style options for individuals to choose from - the Aetna Individual Advantage(SM) Dental PPO Plan and the Aetna Individual Advantage(SM) Dental PPO Plus Plan. Both plans will give members access to Aetna's PPO network of participating dental practices, which includes more than 105,000 available dental practice locations throughout the country.

Individuals can find more information on these plans and purchase them directly at www.aetna.com/buydental or by calling 1-877-243-3682.

"The fact that 47 million individuals in our country do not have health insurance is often mentioned, but it is rarely noted that more than twice as many individuals lack dental insurance," said Frank McCauley, head of Aetna's Consumer Business Segment. "We believe that a stand-alone dental product will help increase access to important dental care."

Aetna's Emphasis on Dental Health

AdvertisementRecently, numerous studies have demonstrated the connection between dental health and overall health. This includes research conducted by Aetna and the Columbia University College of Dental Medicine that shows a correlation between periodontal disease and individuals with chronic conditions, including people with diabetes or heart disease.

"Our research with Columbia indicates that promoting preventive dental care can have an impact on the overall wellness of our members," said Alan Hirschberg, head of Aetna Dental.

In addition to this research, Aetna has worked with Columbia to develop a number of continuing education courses for participating dentists on the connection between dental health and overall health. Columbia also provides the content for Aetna's dental education website, Simple Steps to Better Dental Health(R).

June 01, 2008

Stephen Barkalow focuses on health care, education

Many of the problems plaguing California, notably the economy and education, can be ameliorated by focusing on fixing the ailing health care industry, according to Assembly candidate Stephen Barkalow.

When he first became active in the political arena, he wanted to focus on education and health care reform.

“But then I saw that they all bleed together,” he said. “I decided to focus on the issue that affects us the most.”

Barkalow has been a practicing chiropractor for about three decades. In his practice, he sees about 30 patients per day.

For 15 years, he’s been actively lobbying Sacramento for changes to the health care industry, especially in the for-profit health insurance industry.

About 20 million people in California are privately insured or have obtained coverage through their places of employment. Altogether, they are paying out billions in premiums, but private insurance companies keep 50 percent, said Barkalow.

This is having severe negative financial impacts on consumers, and leading to an overall decline in the health care industry, he said.

He says that if California takes a stand against for profit health insurance companies, it will give money back to consumers and pump billions back into the economy. Some states, said Barkalow, require their health insurance companies to pay out 90 percent.

“If we change these things, that money stays in our pockets,” he said. “We would keep $50 billion. Across the board we’d have a healthier California.”

May 29, 2008

Poll: 7% of Americans marry for health insurance

Some people marry for love, some for companionship and others for status or money. Now comes another reason to get hitched: health insurance.

In a poll released Tuesday, 7 percent of Americans said they or someone in their household decided to marry in the past year so they could obtain health care benefits via their spouse.

"It's a small number, but a powerful result, because it shows how paying for health care is reflected not only in family budgets, but in life decisions," said Drew Altman, president of the Kaiser Family Foundation, which commissioned the survey as part of its regular polling on health care.

The survey found that the costs of health care outranked housing expenses, rising food prices and credit card bills as a source of concern.

Of those surveyed, 28 percent said they had experienced serious problems because of the cost of health care, nearly tied with 29 percent who had problems getting a job or a raise.

Gasoline prices were the top economic worry, with 44 percent saying they had serious problems keeping up with increases at the pump.

May 26, 2008

What Is The Difference Between Health Insurance Companies In California?

Whether you already know it or not California has a lot of options for health insurance. There are companies that we all heard of and there are some companies that we never heard of. With all the Health Insurance Companies out there you might be wondering what the differences are and which one is right for you.

First in state of California the health insurance companies you should be looking at are; Aetna, Assurant, Blue Cross, Blue Shield, HealthNet, Kaiser, Nationwide, PacifiCare, Celtic and new company that is going to be available in state of California is Golden Rule. These are the largest health insurance carriers that are available in the State of California.

If you are looking at any other company that was not mentioned previously, use caution. With all the health insurance premiums going up there are companies that prey on people with low premiums and coverage that does not cover anything. They are just out there to make a quick buck buy collection as much premiums as they can before you cancel your coverage. Stay away from companies that you never heard of, not matter what they tell you. If you hear something like, “affordable health insurance for self-employed”, run.

Second what you have to understand that the actual cost of insurance no matter what company you go with is about the same. So how do insurance companies have so many different plans with different premiums? If it is a large insurance company and the company ran efficiently that is how you get great premium with great coverage. What creates variety of prices for insurance coverage is the creative aspect of the insurance company designing their plans. The way they do it is by deductibles, co-pays, co-insurance, drug coverage deductibles, whether the plan covers brand name drugs or generic drugs only, maternity coverage, maximum out of pocket, deductible and co-pays for all kind of different services.

The name we all know is Blue Cross Blue Shield. Blue Cross has been around since the recession of 1929, and it used to cost only 1 cent a day. The times have changes since then, but the Blue Cross name is still around. Blue Cross has been over the years the most stable largest health insurance provider in the United States. Their strategy is to keep rates stable and have stable rate increases. While most other plans might lower their rates to get more people on their coverage and then keep increasing their rates. There fore as some plans might be more attractive in premiums at the moment over time eventually they have to catch up with the actual market health insurance cost. Sometime the company has to charge people more for health insurance in the future so they can give more affordable rates today. Blue Cross will give the one of the largest varieties of plans to choose from and you can always downgrade a plan without going through underwriting is the monthly premiums because to expensive.

May 22, 2008

California Insurance Regulator Touts Value of Personal Health Records

Today, the Department of Insurance is expected to issue a report that urges Californians to use personal health records, the Sacramento Bee reports.

The report found that PHRs are efficient, secure and increasingly widely available. PHRs also can provide consumers with a better way to manage their health care and deal with health insurance claims, according to the report.

May 15, 2008

Kaiser agrees to offer coverage to 1,000 canceled patients

Kaiser Permanente has agreed to offer insurance to 1,092 individuals whose policies were inappropriately canceled after they got sick and to refund money paid to the health plan for medical care.

The health plan has also agreed to provide a fair and speedy process to resolve any additional expenses incurred due to a gap in coverage, Kaiser officials and state regulators announced Thursday.

Kaiser is the first of five large California health plans to reach settlement with the state Department of Managed Health Care over the controversial practice of rescinding individual insurance coverage after patients got sick, claiming they had pre-existing conditions and did not qualify for coverage.

The agreement includes a $300,000 fine against the health plan and a potential fine of $3 million if Kaiser fails to pass a survey of its practices by state regulators within the next 18 months.

An agreement with Health Net Inc. is pending. It will cover 85 individuals who had their policies canceled since 2004, said agency director Cindy Ehnes. Her department is in discussions with the other three plans: Anthem Blue Cross, PacifiCare and Blue Shield of California.

"Kaiser is the first to step up," Ehnes said in a press call Thursday. The $300,000 fine and potential $3 million penalty are unique to Kaiser, she said. Other settlements will reflect the circumstances at other health plans.

Jerry Fleming, national health plan manager for Kaiser, dubbed the deal as a "fresh-start" program that will immediately provide coverage for individual members whose policies were rescinded with no medical questions asked.

Kaiser voluntarily halted the controversial practice, known as "rescission," in October 2006 after questions were raised about the application survey used.

On April 17, Ehnes ordered the five health care plans to immediately reinstate coverage for 26 people whose insurance benefits were wrongly canceled after they filed claims -- and ordered a review of thousands of additional cases.

May 13, 2008

California Health Insurers Must Reinstate Policies

Chalk one up for sickly patients. California regulators have ordered insurers there to reinstate the health insurance policies of 26 people who lost their coverage after the insurers claimed they had lied on their applications, according to news reports. The 26 cases represent the most egregious examples of insurers wrongly "rescinding" policies, typically for inadvertent errors. The person gets sick and starts making expensive claims, and the insurer cries "fraud!" The patient says "forgot!" or sometimes "say what?" For example, one woman I spoke with on this topic had answered "no" when asked if she'd been treated for cancer in the past 10 years. Later her policy was yanked because the insurer claimed that regular blood work she had to ensure her earlier cancer had not returned constituted cancer treatment.

Now California begins a case-by-case review of thousands of rescissions in the past four years, and it may be that these 26 are the tip of a fairly hefty iceberg. And consumer advocates say there's no reason to believe this issue is confined to California. They expect similar cases to begin emerging elsewhere.

These problems arise in the individual health insurance market, where people buy policies on their own. That market is much more loosely regulated than the group market—and often more problematic for patients—as I discussed a few months ago.

Right now, only about 5 percent of people buy insurance this way. But if Sen. John McCain has his way, many more would very likely start buying health insurance on their own. The presumptive Republican nominee has proposed eliminating the tax break that employees currently get on their health insurance benefits and instead giving people a tax credit of $2,500 for individuals and $5,000 for families to put toward buying coverage. I also wrote today about the presidential candidates' healthcare reform proposals.

Many policy analysts see merits to the restructuring that McCain proposes, but they argue that without better regulation of the individual market, people who are older or sick won't be able to get affordable health coverage, or any coverage at all. They point to what's going on in California as an example of the kind of problems that can occur. "Look at the rescission mess in California," said health policy analyst Robert Laszewski, when I interviewed him for the election health reform piece. "The Democratic nominee will stand up and say, 'John McCain will throw you to the market wolves.' " McCain is expected to elaborate on his healthcare reform proposal at the end of April. Maybe at that time he'll offer details about how he plans to protect consumers from predatory insurance practices.

As for this rescission mess, I'd like to hear from people who've experienced problems similar to what's occurring in California. Is this just a left coast phenomenon, or is it happening elsewhere, too?

May 08, 2008

Single-Payer Healthcare: a Reality for California?

As a nurse, I have seen countless examples of the devastating outcomes that result when people do not have access to care due to lack of insurance. Just last week, I visited a 35-year-old cancer patient to help her manage oxygen treatments at home. She had beaten breast cancer at age 25. However, she was a restaurant worker and did not have health insurance; consequently, once she started working again, she no longer qualified for MediCal and could no longer see a doctor to be screened for recurrence. Sadly, when the cancer did come back it was not detected until she went to the ER one night when she could no longer breathe. Cancer metastases cover most of both her lungs. As she can no longer work, she is once again eligible for MediCal. Unfortunately, this coverage has come too late to save her life. I wish this story was an isolated event, but the fact is 18,000 people die in the U.S. every year solely because they do not have health insurance. A single-payer system would not only give access to care to the millions of currently uninsured, it would also create a better environment for all healthcare workers to practice in.

The reality of a single-payer system for California may not be as far away as you think. Senate bill 840 – a proposal for single-payer healthcare in California – was passed on the floor of both the Senate and the Assembly last year (only to be later vetoed by the governor). It will be re-introduced in the upcoming months. State Senator Sheila Kuehl, author of SB840, explains the rationale behind the bill: “SB 840 would replace insurance companies with a statewide trust fund that collects premiums paid by employers and individuals. The creation of a single state fund reduces the administrative portion of California’s healthcare costs from nearly 30 percent to under 10 percent. With everyone in one pool, which spreads the risk as widely as possible, no one would be denied coverage for a preexisting condition. Individuals would be free to change jobs, start a business, go to school or start a family without losing coverage or doctors they trust.”

SB 840 is good for the practice of healthcare, as well. Under this new system, decision-making would be returned to physicians and advanced practice nurses as treatment options would no longer be determined by what is covered by each individual’s insurance plan. SB 840 would end uncompensated medical care by ensuring that everyone has a payer. Paperwork would be infinitely streamlined and medical offices would no longer need teams of administrators to argue for authorization and bill dozens of different insurance companies every month. Practices will be able to refocus their staffing on nurses and other providers, which will increase the quality of care and decrease medical errors. Continuity of care will improve as patients are no longer forced to change medical groups when they switch jobs or their employers switch plans. This will lead to more meaningful, long-term relationships between providers and patients – improving quality of care and patient safety.

May 06, 2008

Health care reform - what are the chances?

There is a retty good chance of implementing successful health care reforms in this country making health care available to more people and to provide affordable health insurance to more families and individuals. Probably there is 60:40 chance or better that there will be major reform in the next Congress.

Here's why.

Sen Ron Wyden's (D OR) Healthy Americans Act has six D and six R Senate cosponsors, including Bob Bennett (R UT). There is broad bipartisan support for the bill, which mandates universal coverage.

WalMart and the SEIU back the bill.

The National Federation of Independent Businesses backs some form of 'universal' reform.

Both Democratic Presidential candidates back major reform.

Congress has been stung by criticism of its inability to get much done - and health care reform is something big that needs doing.

Many of the Fortune 500 back reform, including automakers, service companies, and manufacturers. And the unions that represent their workers do too.

This impressive array of supporters is opposed by...well, it must be opposed by some groups, companies, politicians, lobbies, but it is hard to find much in the way of opposition, at least using internet search engines. We can look to California to find out how and why their efforts to pass reform failed. A loose coalition, comprised of Republican legislators, Blue Cross of California [WellPoint], the state Chamber of Commerce, and the tobacco industry joined together to oppose the bill, and their efforts got a major push from legislators' deep concerns about the cost of the initiative and the Golden State's financial straits. A closely related issue is the concern by many that states, acting alone, cannot enact meaningful reform for the simple reason that 1/3 of all health care dollars are controlled (to a great extent) by the Feds, and if these dollars, and the care they pay for and members they cover aren't integrated into a comprehensive reform measure, the effort is doomed to fail. Cost shifting, contradicting priorities, differing measures of success and evaluation methodologies will result in a confused, bifurcated system that serves neither population well.

Similarly, the problems emerging in Massachusetts and Maine make it less likely that states will successfully pursue reform measures. Instead, the states, a powerful lobbying group in and of themselves, will likely join others to support national reform.

May 01, 2008

Cracking down on fraud in California managed health care

Are you uninsured? Unfortunately, you are not alone. In California, out of a total population of nearly 36 million people, 18.4 percent do not have health insurance coverage. Some lost their insurance when they lost their jobs. Others may be working, but their jobs don't provide health insurance benefits. Whatever the reason, finding and keeping health insurance can be difficult.

This week is Cover the Uninsured Week, a national effort to highlight the fact that too many Americans are living without health insurance and to encourage all of us to come together and seek solutions.

We know that reaching the goal of affordable and stable health care for all requires changes in public policy. Governor Schwarzenegger continues to work towards covering everyone regardless of ability to pay or preexisting health conditions. The California Department of Managed Health Care (DMHC), under his leadership, has been working to increase quality, affordable forms of comprehensive health insurance.

In the absence of successful efforts to reform our health system, however, alternatives to health insurance have cropped up in the marketplace. One is a discount health plan -- which may not be truly offer a worthwhile discount and may even be fraudulent.

The idea behind a discount health plan is a membership program which offers reduced-rate health care services to the public. These plans typically charge an annual membership fee and a monthly payment in exchange for a list of health care providers who will deliver services to members at a discounted rate. Members must then pay directly for the health services. The discount plan is not insurance; meaning that neither the plan nor any other entity assumes financial risk to pay providers for delivering services. It is more of a pay-as-you go service, but at less cost than the normal fee that an uninsured person would pay.

April 29, 2008

California voters feel let down on health care plan

Just a few months after the governor's state health-reform proposal collapsed, it appears California voters liked his idea by a landslide. And now they're feeling more insecure and pessimistic than ever about the future of medical coverage.
That's the gist of a new survey released today by the non-partisan Field Poll and paid for by the private California Wellness Foundation.

A whopping 72 percent of voters interviewed by pollsters said they generally favored Gov. Arnold Schwarzenegger's plan, even as they had some concerns about the funding scheme.

"The governor and the Legislature were clearly on the right path," pollster Mark DiCamillo said. "They had the support of the public."

But Sacramento politicians also faced a budget shortfall roughly equal to the $14.7 billion cost of the health-care bill. The proposal died in the state Senate's health committee, winning only one vote from a Democrat.

"It was a bad circumstance of timing," DiCamillo said. "The budget was under pressure from every quarter to just maintain."

Still, some supporters of the bill feel vindicated today.

"This was absolutely a blown opportunity," said Elia Gallardo, government affairs director for the California Primary Care Association. The organization lobbies for community clinics, which stood to gain about $140 million a year. She said one-fourth of the 4 million clinic patients don't have health insurance.

To those polled, the future of health reform looks bleak. Three times as many expect the health care system to get worse in five years as think it will improve - 39 to 13 percent. The Field Poll found the same sense of impending catastrophe in a similar survey in 2006. But in some specific categories, such as losing coverage completely, worries appear to be running higher today.

Like most surveys of this type, the Field Poll interviewed a small sample of voters, in this case 1,202, who more or less reflected the state's political and demographic diversity.

Jose Mora, a retired Democrat from Morgan Hill, supported the health insurance plan even though he didn't think its new fees, taxes and mandates would have covered the full cost.

April 24, 2008

Health insurance a matter of life and death: study

Whether or not a person has health insurance can mean life or death, according to “Dying for Coverage” a recent Families USA report for all 50 states and the District of Columbia. The report revealed the number of Americans expected to die in each state, each week because they don’t have health care coverage.

Families USA is a national non-profit that advocates for affordable, high quality health care.

Using data from a 2002 groundbreaking national federal study, Dying for Coverage demonstrated direct links between a lack of health coverage and deaths from health-related causes. It found more than 7 working-age Texans die each day due to a lack of health insurance. “Our report highlights how our inadequate system of health coverage condemns a great number of people to an early death, simply because they don’t have the same access to health care as their insured neighbors,” said Ron Pollack, executive director of Families USA.

“Health insurance really matters in how people make their health care decisions,” he continued “We know that people without insurance often forgo checkups, screenings and other preventive care.” The study was released April 8.

For Khalilah Ali, a Dallas based family nurse practitioner, the findings are no surprise. Her Supreme Wisdom Family Health Clinic specializes in serving the medically underserved. “People in Dallas that don’t have health insurance are usually referred to Parkland Hospital, the place where President John F. Kennedy died. They have very long waits and I believe receive substandard care. Health insurance makes the difference,” she said.

Mrs. Ali drives around Dallas making house calls like country doctors of days gone by. “There is an epidemic of high blood pressure and diabetes in the Black community. For many people even when they have medicine, they save it so they don’t run out. That can be deadly because their blood pressure is always high.

“Even the seniors who have Medicare which only pays 80 percent, many still can’t afford to buy their prescriptions. So they take half of their medicine, or cut the pills in half, or only take it when they have symptoms of their illness,” she said.

April 22, 2008

The Truth About Mandatory Health Insurance

Hillary Clinton's supporters attacked Barack Obama [in January] for not proposing a federal mandate that every American buy health insurance. Mr. Obama's health insurance plan, they said, is a "Band-Aid" for the nation's gaping wound: 47 million people without health insurance. Mrs. Clinton would require all Americans to get coverage. Presidential candidate John Edwards and Christopher Dodd say they would, too. Not Mr. Obama.

Imposing a federal mandate is a hot issue on the campaign trail. It's also a burning issue in Congress, where Democratic Sen. Ron Wyden and Republican Sen. Bob Bennett are pushing the Healthy Americans Act, which would require everyone not in Medicaid or another government program to get health insurance.

'Shared Responsibility'

But is mandatory health insurance really a good idea? Requiring catastrophic coverage (our parents called it major medical) probably is smart. This would ensure that a person who is hurt in a car accident or diagnosed with a costly illness can pay his own medical bills, instead of being a burden on society.

But catastrophic coverage is not what the mandate advocates want. They would require that everyone have comprehensive health insurance, covering preventive and routine care.

The rationale for this mandate is not personal responsibility but "shared responsibility," a polite way of saying shared costs. Requiring comprehensive coverage, the argument goes, will make it affordable for the sick, by pulling the young and the healthy--neither of whom use these health services very much--into the insurance pool. Advocates also argue that requiring this type of coverage will cure overcrowded emergency rooms and help tame skyrocketing health care costs.

Ehnes, whose department has investigated rescission practices at those plans since 2005, has scheduled a news conference for 1 p.m. PDT in Sacramento. California already has levied fines for rescissions against several health insurance plans that offer individual policies in the state. Last fall, the state fined Health Net $1 million for failing to disclose a link between employee bonuses and the cancellation of individual insurance policies.

The state's managed-care regulators aim to stop what they consider an illegal industry practice: rescinding individual health coverage, sometimes after members have become sick, based on inadvertent or insignificant omissions on enrollment applications.

Ehnes and California Insurance Commissioner Steve Poizner last year proposed joint regulations to protect consumers in the individual health-insurance market from illegal rescissions.

April 11, 2008

Insurance system of U.S. in shambles

One of the big issues for the upcoming presidential election in November is healthcare. Democrat candidates Barack Obama and Hillary Clinton, in some form or another, want to mandate that individuals be required to purchase healthcare coverage. Republican candidate John McCain wants to allow for tax breaks that would help cover the cost of insurance, but he has resisted any steps toward a mandatory requirement to purchase health insurance. But what happens when your health insurance provider decides to stop providing?

Patsy Bates, a California hairdresser, was diagnosed with breast cancer in 2003. She did have health insurance through Health Net, a for-profit health insurance provider in California. But, a few months into her cancer treatment, Health Net suddenly decided they were going to cancel her insurance policy.

“In fact, she was in the hospital getting prepped for surgery when she first learned Health Net was dropping her,” according to a Nov. 9, 2007, report by Bill Whitaker of CBS News. Bates, still in need of treatment, was stuck up the proverbial creek without the proverbial paddle. Bates was forced to quit her cancer treatment regimen until she found a charity to pay for it. She was also hung out to dry for $129,000, the cost of the treatments she received that Health Net refused to pay for.

So what happens when we’re all mandated to buy healthcare and then, when we get sick, our (for-profit) insurance provider drops us like a hot rock? Sounds like a big, fat, mandatory payday for the insurance companies, if you ask me! And, if you just happen to have any “pre-existing” conditions before you’re mandated to purchase health insurance, it’s an even bigger payday for the health insurance companies. Luckily, at least for Bates, in this case the good guys won.

April 08, 2008

Who’s Opposed to Informed Choices on Health Insurance by Californians?

I'm a good bargain shopper. (My prize: 10-piece set of top tier Calphalon pots once for $70) Here are my rules for assessing a good bargain:

1. Is it a known product (do I know it's a quality product -- like Calphalon)

2. If it's marked down, is it a good price compared to other similar products

3. Lastly, will I use it (because it does me no good to get a good deal on shoes if I'm not going to wear them...and I've done this way too much).

This mental checklist is meant to ensure that the product is of value to me.

Which brings me to the letters submitted by the health insurance industry SB 1522 (Steinberg), which create standards for health insurance that would enable any person to go through such a checklist when buying insurance on their own. (See our Fact Sheet on SB 1522.)

In short, SB1522 would:

1. Classify health plans into five "tiers'' so consumers would know what they were buying - i.e. a top tier plan means comprehensive, bottom tier means "catastrophic.'' (Known/quality product)

2. Insurers would have to have at least one plan in eacth tier, enabling apples-to-apples comparisons.

3. Establish minimum benefits, which would weed out junk insurance -- such as "hospital only'' plans that barely covers the hospital visit. (will I/can I use it?)

Let's step back a bit. Let's say you don't receive health insurance on the job now and have to go out and scavenge for a decent plan. Go to http://www.insuremyhealth.com/ and you'll get hit with 107 plans with all manner and range of co-pay, deductible, premium, office visit policies.

The "choice'' argument: Insurers argue that SB1522 will lead to a reduction in consumer choice. First off, their argument is bogus. Choice will still exist; it will just be more organized and limited. And limiting choice for consumers is actually a good thing, according to research on a parallel issue-401(k)s (the research on choice can also be applied to choosing ice cream, jams and insurance policies):

"...Findings from this study show that an extensive array of options can at first seem highly appealing to consumers, yet it can also reduce subsequent motivation to purchase this product...the very act of making a choice from an excessive number of options might result in "choice overload,'' in turn lessening both teh motivation to choose and the subsequent motivation to commit to a choice....''

That research correlates with private polling of uninsured and individual market participants, which also reveals that consumers do not have confidence in their understanding of what the insurance plans provide, nor do they trust the literature that is provided by the plans.

SB1522 would provide choice, but in an organized fashion so that consumers could go through their mental checklist and feel comfortable about a "known product'' and make comparisons against other plans.

April 03, 2008

Cautionary Health Care Tales

The collapse of health reform in California and ominous signs from Massachusetts spell big trouble ahead for reforming the nation's health care system no matter who is elected President. The lessons from those states, which have tried hard to bring insurance coverage to all residents, are worth heeding for anyone sitting in the White House next year. They also raise the question of whether it is possible, either fiscally or politically, for states to do the job. Indeed, failure in California and troubles in Massachusetts indicate that the underlying problems that bedeviled reform efforts fourteen years ago are still with us, and could doom yet another attempt to change the American way of health care.

Although Hillary Clinton and Barack Obama try to distinguish between their plans, both are variants of the Massachusetts model. That scheme requires everyone to get health coverage, and it imposes tax penalties on people who don't -- the so-called "individual mandate." In both Obama's and Clinton's plan, people do not have a right to health insurance, as is the case in truly universal national health insurance systems, such as in France and Canada, where everyone is guaranteed coverage, with care paid for through a broad-based tax. Instead, both candidates have used the word "universal" to describe a potpourri of options that could bring coverage to some portion of the population currently not covered while keeping commercial insurance in the game. Clinton's plan includes an individual mandate. Obama would require coverage only for children and touts cost-control measures that he says would lower premiums so much that the uninsured could afford them, obviating the need for a coercive mandate. Clinton would boost coverage by requiring large employers to cover their workers, giving incentives to smaller ones to do the same. Obama would make employers provide "meaningful" coverage or contribute to a public plan. Both proposals call for some sort of public alternative that people can buy into if they don't like the market choices, and both try to control medical costs with weak remedies like improved information technology and better care coordination.

Significantly, the premium subsidies and tax credits that Clinton, Obama, and John McCain support to help low-income families buy insurance are a traditional Republican strategy that President Bush has pushed for years. But at least 55 percent of the uninsured already pay no taxes, so unless the credit is made available to non-tax filers, this approach would leave lots of people without coverage. To be useful, subsidies must be high enough to help families pay the annual insurance premiums -- now averaging about $12,000 -- but low enough so the government doesn't go broke. And therein lies the devil that killed reform in California and could do in the much-hailed Massachusetts plan as well: the money just wasn't there.

March 29, 2008

Clinton Details Premium Cap in Health Plan

Senator Hillary Rodham Clinton said in an interview on Wednesday that if elected president she would push for a universal health care plan that would limit what Americans pay for health insurance to no more than 10 percent of their income, a significant reduction for some families.

In an extensive interview on health policy, Mrs. Clinton said she would like to cap health insurance premiums at 5 percent to 10 percent of income.

The average cost of a family policy bought by an individual in 2006 and 2007 was $5,799, or 10 percent of the median family income of $58,526, according to America’s Health Insurance Plans, a trade group. Some policies cost up to $9,201, or 16 percent of median income.

The average out-of-pocket cost for workers who buy family policies through their employers is lower, $3,281, or 6 percent of median income, according to the Kaiser Family Foundation, a health research group.

A cap on premiums has been part of Mrs. Clinton’s universal coverage proposal since she announced it in September. Her published plan did not disclose her thinking on where to place the cap. She also said in the interview that she preferred to set the limit at a single level for all Americans rather than varying it by income.

Mrs. Clinton, a New York Democrat, set out a comprehensive approach to her signature issue of health care in three speeches last year, but she has been criticized for not providing details on several crucial components. She largely continued that approach in the interview, saying she would leave particulars like the eligibility criteria for her proposed health insurance tax credits to negotiations with Congress.

March 25, 2008

Must you buy health insurance?

An important element is being overlooked in the healthcare debate between the Democratic presidential candidates: namely, whether the plans they propose are constitutional.

The largest difference between their healthcare plans is that Sen. Hillary Rodham Clinton would "mandate" that everyone (with limited exceptions) purchase private health insurance. Although Sen. Barack Obama's plan also contains a mandate, it is much narrower – it is required only for children. Mr. Obama relies principally on subsidies, economies of scale, and regulation to achieve his version of universal coverage.

Are health insurance mandates constitutional? They are certainly unprecedented. The federal government does not ordinarily require Americans to purchase particular goods or services from private parties.

The closest we come is when government imposes a condition on the grant of discretionary benefit or permit. For instance, in most states, you must have auto insurance to drive a car, or you are required to install fire sprinklers when building a new house. But in such cases, the "mandate" is discretionary – you don't have to drive a car or build a house. Nor do you have a constitutional right to do so.

But Americans do have a constitutional right to live in the United States. Accordingly, neither federal nor state governments can require you to purchase health insurance as a "condition" for residency. The Supreme Court has drawn a distinction between requirements that are flat-out imposed by government and those imposed as a condition for discretionary benefits.

The health insurance mandate proposed by Clinton is similar to the one enacted in Massachusetts under former Gov. Mitt Romney and the plan proposed by Gov. Arnold Schwarzenegger for California. These "unfunded mandates" are unlike any form of government regulation we've seen.

In making the case for her plan to mandate private health insurance, Clinton said in a recent Democratic debate that not doing so "would be as though Franklin Roosevelt said, 'Let's make Social Security voluntary,' or if President [Lyndon] Johnson said, 'Let's make Medicare voluntary.' "

In fact, under the law, there's a big difference between participation in a government health program funded by taxes and privatizing such a program, with individuals forced to purchase private health insurance.

March 23, 2008

Report: Health insurance a matter of life or death

Each day, local newspapers run obituaries of Iowans who have died. Causes of death range from cancer to car accidents. It's unlikely anyone recalls seeing "lack of health insurance" as a reason for death.

However, about three obituaries each week should list that cause, according to a new report from Families USA, a national organization for health-care consumers. Nearly three Iowans die each week in part because they don't have health insurance, the report found. Many have serious illnesses that could have been treated effectively if detected earlier.

"The conclusions are sadly clear - a lack of health coverage is a matter of life and death for many Iowans," said executive director Ron Pollack.

This is relevant information as the lawmakers consider health reforms. Much of the conversation at the Statehouse is centered on insuring children - a less costly and easier group to cover because many are eligible for government programs.

It's a reminder that health reform must address coverage for this demographic of Americans. Unlike children and seniors, they frequently aren't eligible for government health insurance unless they're poor or disabled. Private health insurance may not be offered through an employer or is unaffordable.

Adkins recently changed his Web site, posting what he charges for everything from office visits to lab work. For example, an initial office visit can run from $75-$100 or $125, while lab work varies from $8 for a glucose blood test to $100 for the human papilloma virus.

His move is part of a national push toward greater transparency in health care, as more Americans go without health insurance and there's expected to be an increase in people moving to high-deductible health plans that force them to consider the cost of services.

Thirty-three states, including California, Florida, and Michigan, have laws that require price transparency, according to the Deloitte Center for Health Solutions. Some medical and policy experts believe greater transparency will lower care costs.

"What triggered it with me is when I started seeing everyone laid off," Adkins said.

Nationally, 47 million Americans are without insurance, according to industry reports. The figure is likely to grow as the economy slides. Fearing the cost of care, many who are uninsured won't seek help until their conditions land them in emergency rooms.

Adkins then started considering the number of Americans who are expected to move into consumer-driven health plans: high deductible, low-premium products that are generally linked to a medical savings account or reimbursement agreement. Twenty-four million Americans were enrolled in consumer-driven plans as of January 2006, according to the Government Accountability Office, the latest data available.

March 14, 2008

The Next Failure of Health Care Reform

A major problem -- if not the major problem -- for many people living in the U.S. is the difficulty of accessing and paying for medical care when they are sick. For this reason, candidates in the presidential primaries of 2008 -- the Democrats more often than the Republicans -- have been recounting stories about the health-related tragedies they have encountered in meetings with ordinary people around the country (an exercise conducted in the U.S. every four years, at presidential election time). These stories tell of the enormous difficulties and suffering faced by many people in their attempts to get the medical care they need. I have been around long enough -- I was senior health advisor to Jesse Jackson in the Democratic primaries of 1984 and 1988 -- to know how frequently Democratic candidates, over the years, have referred to such cases. The only things that change are the names and faces in these human tragedies. Otherwise, the stories, year after year, are almost the same.

In the Democratic Party primaries of 1988, for example, candidate Michael Dukakis talked about a young single mother who had two jobs and still could not afford medical insurance for herself and her children. In 1992, Bill Clinton did the same, changing the story only slightly. This time it was the case of a woman with diabetes who could not get health insurance because of her chronic condition. And now, in the 2008 primaries, Hillary Rodham Clinton (whom I worked with on the White House Health Care Reform Task Force in 1993) describes a similar case. This time it is a single woman, with two daughters, who cannot pay her medical bills because her congenital heart defect makes it impossible for her to get medical insurance coverage. And Barack Obama describes similar cases, with the eloquence that characterizes all of his speeches. He frequently refers to his own mother, who had cancer and had to worry not only about her illness but about paying her medical bills.

All these cases are tragic and are representative of a situation faced by millions of people in the U.S. every year. But, I am afraid that unless the winning Democratic candidate, once elected president (and I hope he or she will be), develops a more comprehensive health care proposal than any of those put forward in the primaries so far, we will see the same situation continue. Democratic candidates in the 2012 primaries, and in the 2016 primaries, will still be referring to single mothers with chronic health conditions who cannot pay their medical bills. The proposals put forward by Obama and Clinton underestimate the gravity of the problem in the U.S. medical care sector. The situation is bad and is getting worse: the number of people who are uninsured and underinsured has been growing since 1978.

March 13, 2008

Vertical health destination and search engine Healthline has teamed up with US health insurance carrier Aetna to offer what the company is calling Aetna SmartSource -- customized health search. The service, powered by Healthline, will roll out on Aetna’s member self-service website and offer personalized search results based on individual health records and profiles. That means that two different Aetna customers searching for "diabetes type II" will see potentially different results based on their individual health histories.

What's different about this vs. what Microsoft, Google and Revolution Health are doing is that it's all taking place within the context of the existing relationship between insurance provider and customer-patient. Aetna already has the health records and histories of its insureds so there's little or no effort for the users to obtain the benefits (so to speak) of the system. In other words, they don't have to construct detailed profiles or upload information themselves.

What's also interesting is that this is the most developed version of personalized search yet in the market. In the relatively protected context of the existing carrier-insured relationship most of the concerns about tracking and data-mining go away. Aetna won't be using search behavior on its site, presumably, to advertise or market products to its customers.

However, in a cautionary tale about corruption in the US healthcare industry, one of Aetna's competitors in California, HealthNet, had a secret practice of canceling policy holders who were perceived as "expensive" in order to save the company money. It actually tied employee bonuses to the number of customer cancellations they accomplished.

March 11, 2008

Calif. Insurance Rulings GCs Should Watch Out For

California appellate courts tackled a diverse array of insurance issues in 2007 that included health care post-claim underwriting, directors and officers (D&O) liability, employee dishonesty and the scope of the attorney-client privilege in the context of insurance. The decisions in these cases will have a direct influence on business processes for companies across many industries, and California general counsel should be aware of how these rulings may affect their companies.

-Health care. In suits that could have an impact on health insurance claims brought by employees, two recent court of appeal decisions held that "post-claim underwriting" by insurers was a prohibited practice. In Ticconi v. Blue Shield of California Life & Health Ins. Co., 157 Cal.App.4th 707, the 2nd District Court of Appeal held that post-claim underwriting of disability insurance policies is prohibited by Insurance Code §10384. The court allowed a case to proceed where it was alleged that the unlawful conduct was post-claims underwriting in which the insurer rescinded disability insurance policies based on alleged misrepresentations in the applications. The applications were incorporated by reference in, but neither endorsed on nor attached to, the insureds' policies, in violation of Insurance Code §10113 and §10381.5.

Also, the 4th District, in Hailey v. California Physicians' Service, 158 Cal.App.4th 452, concluded that Health & Safety Code §1389.3 precludes a health services plan from rescinding a health insurance policy for a material misrepresentation or omission unless the plan can demonstrate that the misrepresentation or omission was willful or that the plan had made reasonable efforts to ensure that the subscriber's application was accurate and complete as part of the pre-contract underwriting process. The court found that an insurer cannot engage in post-claim underwriting and, given the likelihood of inadvertent error in the application process, required an accurate risk assessment by the health insurance plan, which requires a reasonable check on the information the insurer uses to evaluate the risk at the time of the application.

March 08, 2008

Could Your Health Insurance Be Revoked When You Need It Most?

A series of troubling developments in California's individual health insurance market is bringing national attention to the problem of patients having their coverage taken away when they need it most.

Last month, an arbitration judge ordered California-based health insurer Health Net Inc. to pay $9 million to a cancer patient whose individual coverage was canceled during her chemotherapy treatments in 2004. The judge ordered Health Net to repay $129,000 worth of Patsy Bates' unpaid medical bills and awarded the 52-year-old hairdresser $8.4 million in punitive damages and $750,000 for emotional distress.

It's not just Health Net that's attracting scrutiny. Blue Cross of California, a unit of WellPoint, the nation's largest private health insurer, drew fire recently for sending letters to doctors asking them to verify patients' accounts of their health histories in their applications after the company already had approved their policies. Blue Cross has since stopped the letter campaign.

California's Department of Managed Health Care, which regulates the state's HMO plans, has been investigating consumer complaints about unfair rescissions since 2006. The agency has fined both Blue Cross and Health Net and is in the process of reviewing the practices of other companies that sell individual policies in the state, spokeswoman Lynne Randolph said.

"We don't think it is only happening in California...but California's farther ahead in terms of enforcement," she said. "We had a statute in place that companies must do underwriting up front and a consumer must willfully misrepresent their health condition on an application in order for a company to rescind. We feel that means it can't just be an inadvertent omission."

Insurers say they have a responsibility to ensure applicants are truthful about any preexisting conditions they may have so companies can accurately price policies and hold down costs for all their members. But consumer groups warn that tactics such as tying financial incentives to the number of rescissions an employee makes or involving doctors in investigations after policies have been issued aren't working and may be illegal in some states.

March 06, 2008

Taking the LAO in Context on California Health Reform

THE LAO'S INFLUENCE: While some have seen the LAO report as a factor in the stalling of AB x1 1 and the California health reform this year, I think the evidence shows that it was the easy excuse--rather than the actual reason--for the Senate to stop the bill. (For example, one Senator said that the LAO report was determinative in deciding how to vote, even though that Senator had announced opposition to the proposal months earlier.)

In other words, the LAO report, along with other factors, helped create an environment where a "no" vote was acceptable and even easy. The LAO has no formal decision-making power, but it does have influence, and its decisions do have political consequences.

PLACING REFORM AT A DISADVANTAGE: But the issue as we look forward is the approach used by the LAO, and the context of how that report is used by legislators. Health Access put out a full analysis of the LAO's take on AB x1 1. Basically, the LAO gave a report on AB x1 1 that indicated that the plan could pencil out for about five years, but that also:

• indicated and quantified all the costs and potential risks, but did little to put those risks in context, to indicate how real those risks were (which ended up overstating several risks);

• did not quantify a single cent of savings or upside potential;

• did not evaluate the risks of the status quo, or propose alternatives to the proposal.

To be fair, the LAO had very little time for its analysis, and many analysts are more oriented to warning you about potential risks than potential benefits.

But that's when it is important for the Legislature to place such a report in context. Legislators routinely pick-and-choose what they like and do not like about the LAO says about the budget and other policy proposals, and this should have been no exception. The Legislature should have placed this LAO analysis alongside the voluminous analyses done by various independent experts throughout the year.

WHY DOES THIS MATTER? This matters for the future of health reform. Under the approach used by the LAO, given the certainty that some legislators seemed to seek, then no health reform would ever pass in California.

Budgets fluctuate over time: if legislators seek certainty that health care will be adequately funded in perpetuity, then health reform is not possible. This is not a standard that is met in Canada or Great Britain, or indeed in Medicare or Medicaid. The LAO failed to book a single cent of savings, even though we have ample evidence that the power of group purchasing is effective, both in public and private health care purchasing.

March 02, 2008

Cutting Off California Health Insurance?

Comprehensive healthcare reform has failed in California. But that doesn't mean health insurance companies will, or should, escape scrutiny from state officials.

As reporter Lisa Girion has ably chronicled in this newspaper, insurance companies frequently revoke patient coverage -- a practice known as rescission -- under questionable circumstances. Girion has written, for example, of cancer patients who have lost their insurance in the middle of courses of chemotherapy. Recently she reported that Blue Cross of California mailed copies of health insurance applications to doctors, asking them to check for preexisting conditions that might be used to cancel their patients' policies -- a strategy that, even if legal, violates the spirit of doctor-patient privilege. Not to mention, possibly, the Hippocratic Oath.

In response to troubling tales such as these, California officials are cracking down on insurance companies. Insurance Commissioner Steve Poizner is investigating gaps in PacifiCare's claims process that resulted in more than 100,000 violations of state law. Los Angeles City Atty. Rocky Delgadillo has set up an investigative team to examine rescissions, and has created a website soliciting reports of unfair denials of care. Assemblymen Hector De La Torre (D-South Gate) and Ted Lieu (D-Torrance) have sponsored bills designed to curb egregious rescissions. Those are worthy undertakings and good bills.

Insurance companies are not always villains. To function, they must be able to assess risk and price policies appropriately. Patients who buy individual policies do not deserve a get-out-of-jail free card that lets them lie on their insurance applications. Sometimes, services will be denied. But the vast majority of patients, who are honest, don't deserve a system that is stacked against them, with underwriting practices that make insurance unaffordable even as companies' profits rise. Some patients have become reluctant to use their insurance for treatment or medication because they fear rate hikes. Certainly, spending thousands of dollars in yearly premiums for individual policies, many with high deductibles and co-pays to boot, should buy better "coverage" than that.

We hope, as officials pay closer attention to health insurance practices, to broaden the debate. How might we regulate insurers to assure that risk management doesn't price vast numbers of people out of coverage? How can we ensure that potential price increases don't scare off essentially healthy patients from seeking necessary -- and ultimately cost-saving -- non-emergency care? What is a reasonable profit for an insurance company? And if such a profit is impossible to attain without forcing catastrophic costs on patients, what then?

February 28, 2008

Health Insurers Address Issue of Nixed Policies in California

The health-insurance industry is racing to defuse a growing furor over retroactive policy cancellations that have saddled some patients with big medical bills and sparked lawsuits.

America's Health Insurance Plans, an industry group, is pushing a proposal with state regulators that would give consumers the right to appeal such policy cancellations, known as rescissions, to an external panel, whose decisions would be binding. Some insurance companies, eager for even quicker action, are preparing to roll out their own independent review programs.

The efforts, which are getting a largely positive reception from consumer groups, are emerging amid public outrage in several states against insurers that have voided policies after the beneficiaries started racking up large claims for cancer or other serious illnesses.

Last week, an arbitration judge in California awarded $9.4 million, mostly in punitive damages, to a hairdresser whose medical coverage was canceled by Health Net Inc. The insurer, which acted while the woman was undergoing treatment for breast cancer, claimed that she had falsified information about her weight and failed to mention a heart murmur. The judge ruled that Health Net's conduct was "reprehensible" and unlawful.

Such cases have cast an unflattering light on insurers' practices of investigating individuals' medical histories after they get sick. The insurers say they have the right to rescind policies when policyholders don't disclose pre-existing medical conditions that would have disqualified them from coverage, or when they misrepresent information on their policy application. The companies say they are protecting the integrity of the underwriting process and keeping insurance coverage affordable for customers.

February 26, 2008

Setting a record for its quarterly giving, Blue Shield of California Foundation (BSCF) today announced the award of $13.1 million in grants to nonprofit organizations and programs to improve the quality of patient care through health technology and to expand health insurance for children who do not qualify for public programs.

Nearly half of the money, $5.75 million, will be used to expand the foundation’s groundbreaking program to dramatically reduce the number of hospital-acquired infections (HAIs). After seeing remarkable success in its nine-hospital pilot project, BSCF will use the grant announced today to expand its innovative California Healthcare-Associated Infection Prevention Initiative (CHAIPI) to at least 100 hospitals.

“Hospital acquired infections put lives at risk and increase consumer costs. We want to dramatically reduce those risks by ensuring hospitals have access to innovative new technologies that help pinpoint and stop the spread of infections,” said Crystal Hayling, president and CEO of BSCF. “Given the results we saw in our test program, we expect the broad expansion of this effort to mean 4,000 fewer patients will contract an HAI in the next year, which translates into 30,000 fewer patient days in the hospital, $60 million in avoided costs to patients and hospitals, and nearly $15 million in bottom-line hospital savings.”

In California, an estimated 150,000 patients suffer from HAIs annually, 9,000 of which result in death. Through CHAIPI, participating hospitals will receive support for new technology and collaborative learning opportunities about best practices. While only not-for-profit hospitals can receive funding, this grant is unique because for-profit hospitals are invited to participate in the collaborative learning sessions and will have the opportunity to purchase the technology at a reduced price.

“We look forward to taking CHAIPI to scale because it has the potential to alleviate untold human suffering and save millions of dollars in unnecessary costs, both for patients and our healthcare system,” Hayling said.

Other health and technology grants announced today include:

* $350,000 to the California Health Foundation and Trust to expand its telemedicine program by increasing the number of telemedicine providers and offering technical assistance to those in the field. Telemedicine is vital in rural, underserved areas.

* $115,000 to the California Society of Thoracic Surgeons to study complications of open heart surgery, and to build a single source of clinical data on which to assess and replicate best practices to improve cardiac surgical outcomes.

* $105,000 to the California Children’s Hospital Association for an initiative to reduce catheter-associated and other infections acquired in neonatal intensive care units.

February 24, 2008

Growing pains for UnitedHealth Group

Organized medicine already has offered its reasons why health plan consolidation is troubling for patients and physicians. In late January, California regulators added 133,000 more reasons to the list.

That is the number of violations of state laws and regulations the California Dept. of Insurance says it discovered in just a one-year period investigating the aftereffects of UnitedHealth Group's $9.2 billion purchase of PacifiCare Health Systems. With more than 1.1 million claims examined, that averages out to one reimbursement and claims handling violation for every nine claims. On top of that, the California Dept. of Managed Care, which regulates HMO operations only, found that in the same 2006-07 period, United-PacifiCare mishandled 30% of claims.

Those numbers paint a stark picture of a plan that grew too big and with too little accountability to the patients and physicians who, in the wake of the merger and the market clout it created, had less choice whether to put up with such shoddy service. (Interestingly, as the California insurance regulators point out, one area in which United skipped the growing pains was in its collection of premiums).

The United-PacifiCare example is a warning to regulators about the dangers of health plan mergers -- some 400 in the past decade, many plagued by their own problems -- and it should make them take a long, hard look before considering approval of any such deal.

The case also shows that regulators need to take the strongest action possible to make plans accountable for their misdeeds. History has shown that colossal health plans don't appear to worry much about the occasional fines that pale in comparison to their profits -- it's merely the cost of doing business.

The California situation may mark a striking departure from that pattern. The state could, assuming all violations are found to meet the more serious standard of "willful," to fine United $1.3 billion. That's 100 times more than the national record of $12.6 million it set in December 2007 in fining Blue Shield of California for improper cancellation of individual policies, a penalty the plan is fighting. So far, the California Dept. of Managed Care has issued a $3.5 million fine to United over just the HMO claims.

February 23, 2008

What Now for California Health Care?

Last month the Senate health committee dumped the Schwarzenegger/Núñez Model ABX1 1, California's trend-setting gadget for health-care repair. Senator Sheila Kuehl, who chairs that committee, tossed it for more personal reasons, other than the obvious $14-billion price tag and state budget deficit of similar size.

Senator Kuehl wants to bring back her own model, SB-840, a government automaton that will fry any remaining individual choice in California health care. Governor Schwarzenegger wisely vetoed this legislation in 2006, but it was reintroduced last year and now lurks in Assembly committee. Governor Schwarzenegger vetoed SB-840 because he knows it would create a government monopoly that would tilt the playing field against individual choice, likely past the point of no return.

Senator Kuehl, ironically, noted that a worrisome aspect of ABX1 1, which aimed for “universal” health care through compulsory purchase of private insurance, was a probable “lack of choice” of doctors and hospitals for patients. But under SB-840, California would implement a Canadian-style, government monopoly, health care system that would simply eliminate patient choice in favor of absolute government control.

In return for, at most, a reduction of four percent of current health spending, Californians would pay a heavy price for SB-840. The price would include a dramatic drop in the number of California physicians, long waiting lists for medical services costing an estimated $1 billion each year, and abuse of "free" health care, costing as much as $9 billion – much more than the amount saved by eliminating “profits.”

February 21, 2008

More Heat for California Insurers Canceling Policies

The running saga over California health insurers canceling policies rolls on. Now, the Los Angeles City Attorney is suing an insurer called Health Net for allegedly rescinding coverage when members submit claims for costly treatments.

The suit, filed yesterday, applies to individual policies. A Health Net spokesman told the Los Angeles Times that the company paid $200 million on claims for those sorts of policies last year. He said the company has reviewed its cancellation policies in the past few years and added an internal independent review to “protect people’s rights in a fair and appropriate way,” according to the LAT.

The City Attorney, who last week launched a Web site focused on health insurance, is also opening a criminal investigation into Health Net’s practice of “paying employee bonuses based in part on canceling policies of people who have submitted substantial medical claims,” the LA Times said. The bonuses got the company into trouble with state regulators last year.

Blue Cross of California, which is owned by WellPoint, is appealing a $1 million fine for rescinding individual insurance policies. And last week, public criticism prompted the company to stop sending letters to doctors, asking them to identify omissions in patients’ health insurance applications.

The industry says it rescinding the policies of consumers who have misrepresented their health histories helps prevent health fraud.

February 19, 2008

California Bill Targets Health Insurance Cancellations

Spurred by complaints that Blue Cross of California and other health insurers cancel patients' policies after they get sick, a Southland lawmaker has introduced legislation that would require state regulators to sign off before carriers drop policyholders for allegedly failing to disclose preexisting medical conditions.

Assemblyman Hector De La Torre (D-South Gate) said his bill was prompted by recent letters from Blue Cross to physicians asking them about new patients' health issues that could be used as a reason for canceling coverage.

De La Torre said his bill was needed because insurance companies "were not intending to abide by the spirit" of a law he wrote last year prohibiting carriers from refusing to pay medical bills for previously authorized services.

"We all agree that if someone is lying and doing willful misrepresentation, then they should not be insured," the assemblyman said. "But the insurance companies should not be taking premium dollars from someone and dumping them."

Health insurance companies contend that weeding out people who may not have been forthright when they applied for coverage is an essential part of keeping treatment costs under control.

"We need to make sure that the process for application, rescission and cancellation is fair," said Christopher Ohman, chief executive of the California Assn. of Health Plans. "But we also want to make sure that the millions of people who do the right thing aren't left paying for the relatively few who don't."

Ohman said his group's members were "analyzing the implications" of De La Torre's bill.

The assemblyman's bill is the latest in a series of legislative, regulatory and legal actions in California in response to aggressive efforts by insurers and health maintenance organizations to drop patients who hold individual policies after they've filed claims.

The practice, known in the health insurance industry as rescission, has been the target of growing criticism from patients, physicians and healthcare reform advocates.

In recent weeks, the state Department of Insurance and Department of Managed Health Care levied $1.3 billion in penalties on Cypress-based PacifiCare for alleged improper claims handling and other violations.

Reviewing health insurers' proposed cancellations is an important safeguard, said Dr. Richard Frankenstein, president of the California Medical Assn. Companies should not be "the judge, jury and executioner," he said.

De La Torre's legislation and similar measures are needed in California as stopgap protections for patients at least until state or national policymakers, health insurers and dozens of other consumer and industry groups can agree on a health insurance plan that guarantees universal coverage, healthcare advocates say.

February 17, 2008

Living Without The California Health Insurance Industry

Blue Cross of California is sending physicians copies of health insurance applications filled out by new patients, along with a letter advising them that the company has a right to drop members who fail to disclose "material medical history," including "pre-existing pregnancies."

The letter wasn't going down well with physicians. "We're outraged that they are asking doctors to violate the sacred trust of patients to rat them out for medical information that patients would expect their doctors to handle with the utmost secrecy and confidentiality," said Dr. Richard Frankenstein, president of the California Medical Assn.

Blue Cross may or may not be within its rights to send out this letter, but they aren't doing anything either illegal or unusual. After all, any profit making insurance company is going to do its best to avoid covering people who are likely to incur large medical expenses. It's just the nature of the beast. If they don't do it, they'll go out of business.

So let's get rid of health insurance companies. They cherry pick clients, add huge administrative costs to the system, and do nothing to drive innovation or bring down costs. What good are they? Tyler Cowen answers:

Let me be clear: the incentives today are screwy. Let me also tell you my ideal world. Insurance companies are judged by honest third party intermediaries. Insurance companies compete like heck to make customers satisfied. Insurance companies monitor doctors, read Robin Hanson, and require evidence-based medicine. Insurance companies which fail at these pursuits either go bankrupt or they must abide by an ex ante contract to permit the exile of their CEOs to Greenland. Every year prices would fall in real terms, quality would improve, and coverage would be expanded. Imagine the whole health care sector working like laser eye surgery or cosmetic surgery.

I believe we know why insurance companies don't work this way, namely monitoring problems; they screw you over instead of serving you and they can get away with it. Go ahead, call me a pollyanna, but modern information technology and measurement can indeed resolve many monitoring problems. We can now monitor central bank performance quite well or show up in Sicily with a credit card and rent a car. Neither was the case forty years ago.

February 14, 2008

Heat is on California Health Insurers

With medical costs rising, record numbers of people losing their coverage and healthcare at the top of the domestic agenda, health insurers found themselves Wednesday in the cross-hairs of regulators, elected officials and law enforcement in California and across the nation.

New York Atty. Gen. Andrew Cuomo said the nation's largest health insurers have rigged rates they pay for physician visits, leaving patients with higher medical bills.

In Los Angeles, City Atty. Rocky Delgadillo has assembled a team of investigators and prosecutors to probe industry practices such as canceling patients' coverage after they get sick. Today he is set to unveil a first-of-its-kind website to solicit information about insurance cancellations and delays and denials of treatment.

The announcements follow a yearlong string of fines and citations against insurers in California. Just last month, amid widening state probes, state Insurance Commissioner Steve Poizner decided to seek as much as $1.3 billion in penalties from Cypress-based PacifiCare as a result of widespread claim problems.

"Our healthcare system is broken, and it's going to take a team effort to fix it," Delgadillo said. "Through our combined efforts, and the efforts of other prosecutors throughout this nation, we can make a real difference in stamping out fraud and abuse, and secure for American consumers the protection they deserve."

The crackdown echoes the frustration of consumers who revolted in the early 1990s against new health maintenance organizations, many of which sought to cut costs by rigidly regulating patients' freedom to choose doctors and limiting the medical care they would cover.

Insurers defend their business practices, saying one of their top goals is to keep health insurance affordable for all. In fact, they say, many of the practices in the spotlight actually are good examples of their value in holding down healthcare costs.

February 13, 2008

Southern California Hospital System Sues Kaiser Permanente

Prime Healthcare Services announced today that eight of its hospitals have filed lawsuits in four different Southern California counties against Kaiser Permanente seeking more than $25 Million for Kaiser's failure to properly pay thousands of claims for emergency medical services provided to Kaiser's HMO members. Under both federal and California law, each of these hospitals were required to provide medical screening examinations to each patient who sought emergency care and such further stabilizing care as was necessary to stabilize the patient's emergency medical condition regardless of the patient's insurance status. Kaiser, as well as other HMOs, is required to reimburse the hospitals for the reasonable and customary value of the emergency services provided. Although Prime Healthcare's hospitals provided emergency care to thousands of Kaiser's enrollees, Kaiser failed to properly reimburse Prime Healthcare's hospitals for the emergency services provided to its members. Instead, Kaiser has routinely denied claims in their entirety, paid only small portions of the claims, and/or reimbursed the hospitals at rates which are far below the reasonable and customary value of the emergency services. For example, Kaiser has failed to pay any portion of Sherman Oaks Hospital's $1.6 Million claim for emergency burn services provided to a critically-injured Kaiser member at the world-renowned Grossman Burn Center who was hospitalized for more than thirty days.

Given the rising costs of providing healthcare and the dramatic increase in the number of uninsured and underinsured patients, many hospitals have been forced to close, file bankruptcy, or limit services. Since 2001 more than 17 hospitals throughout Southern California have closed due to financial constraints and several others were forced to file bankruptcy. As noted by Roger Krissman, Chief Financial Officer of Prime Healthcare Services, "it is especially important that HMOs like Kaiser fairly and properly reimburse providers of emergency medical services because otherwise more hospitals may be forced to close". Mr. Krissman commented further that "Prime Healthcare had no choice but to file lawsuits against Kaiser in order to ensure continued access to healthcare for the members of the communities in which its hospitals are located."

In contrast to financially distressed hospitals, Kaiser reported profits of $1.3 Billion in 2006 and $2.5 Billion in 2007. This is not surprising given that although insurance premiums have increased; the amount of revenue spent on patient care has remained the same or decreased. Rather than spending the increased premiums on patient care, HMOs are using the money on increased layers of bureaucracy and middle management whose job it is to refuse necessary patient care, deny provider claims or find other ways to not pay provider claims properly. According to Dr. Prem Reddy, a board certified Cardiologist and Chairman of Prime Healthcare Services, "HMOs, including Kaiser, ought to be focused on effectively managing patients' care; but unfortunately, they are focused on managing bills". Also, in order to implement a process of working efficiently with Kaiser, Dr. Hassan Alkhouli, Medical Director of Prime Healthcare's Orange County Hospitals, attempted numerous times to arrange for a meeting with Kaiser's utilization managers to address utilization issues but his telephone calls went unanswered.
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February 12, 2008

The Defeat of the California Health Bill

The media has widely and falsely reported the California state senate's resounding defeat this week of a universal health care bill as a rejection of a bold plan for universal health care, and as a blow to efforts nationally. In fact, the defeat of this bill--which was cobbled together by Governor Schwarzenegger and the state assembly leader--should be read as a dramatic plea for universal health care. It is a victory for advocates of real reform.

One of the most progressive, heavily Democratic state legislatures in the nation has refused to support a bill that jerry-rigs a set of reforms into the current system and that fails entirely to achieve health care coverage that is adequate, secure, affordable--and universal. Since the leading Democratic presidential candidates are touting proposals that are similar in many respects, they should pay attention.

The California bill required residents to buy coverage and prohibited the insurance companies from rejecting applicants. It subsidized California's poorest residents, and required employers to subsidize coverage for employees. However, the bill declined to closely regulate the cost of premiums, size of deductibles, or extent of coverage. It did require insurers to spend 85% of premium income on health care--which sounded like an incentive for insurers to raise premiums. Tellingly, one of the most trumpeted features of the bill was the exemption from the requirement to buy insurance coverage if the cost of premiums exceeded 5% of a family's income.

In other words, this bill actually assured many people that they wouldn't need to buy health coverage because they wouldn't be able to afford the insurance premiums.

February 11, 2008

UnitedHealth faces stiff fines in California

At the end of 2007, UnitedHealth Group executives vowed to improve their operations and physician relations after saying the company lost 315,000 commercial members, mostly because it mishandled the 2005 acquisition of PacifiCare.

In late January, California insurance regulators offered their own numbers to measure how badly they believed United mishandled the PacifiCare deal.

Another number -- $1.3 billion -- is the maximum fine the California Dept. of Insurance could levy on the health plan. While analysts consider that amount unlikely, United still could face a hefty fine depending on how many of its apparent violations of state laws and regulations on paying medical claims are deemed "willful." Each "willful" violation is a maximum $10,000 fine, and each not considered intentional is a maximum $5,000.

Even if all are considered non-willful, then United could face as much as a $650 million fine -- about 50 times greater than any penalty the department has ever imposed, and a similar proportion greater than the $12 million paid last October in a 36-state settlement over payment practices.

That's because of one more number: 133,000. That is how many violations the insurance department said it uncovered, representing a period between June 23, 2006 and May 31, 2007. Meanwhile, the managed care department said 30% of the medical claims it reviewed were improperly denied. The insurance department regulates PPOs, while the managed care department regulates HMOs, and they conducted a joint, eight-month investigation into PacifiCare.

February 09, 2008

California Health Reform Bill: Unfairly Favored Insurance Companies

While the California health care reform bill "was touted as a fix to our broken health care system," it is "clear that this proposal was bad for consumers and unfairly favored insurance companies," state Sen. Leland Yee (D) writes in a San Francisco Chronicle opinion piece (Yee, San Francisco Chronicle, 2/5).

Yee continues, "This bill was not a step in the right direction, but a huge jump backward for working families who lack health care" because "it would have required consumers to buy their policies regardless of cost." Under the bill, "all Californians would have been required to buy insurance with no caps on premiums, no regulation of the costs of insurance or medical expenses, no maximum deductibles and no clearly defined minimum coverage," Yee writes. The bill also "would have provided incentives for employers who now provide benefits to cancel coverage in order to pay cheaper premiums or shift more costs to workers," according to Yee.

Yee writes that consumers "would have been forced to foot the bill so insurance companies could profit," adding, "Instead of pushing such a fatally flawed legislation, we should all be fighting to change our failing health care system without penalizing those who can least afford it" (San Francisco Chronicle, 2/5).

February 07, 2008

Before voting in the presidential primaries in 2008, it's important to know where the candidates stand on essential mental health care issues. Do they support mental health parity -- requiring mental illnesses to be covered by insurance the same way as physical conditions? What about people who can't afford insurance, or those who cannot get insurance because of being diagnosed with a mental illness?

We will be following the top candidates in each party for their positions on health care as it relates to those with mental illnesses. This page will be updated if the ranking of candidates change and/or when a candidate announces a new or changed policy.

The Florida Primaries held on January 29th shook up the political landscape of the election.The next morning, January 30th, Jon Edwards announced his withdraw from the campaign; Rudy Giuliani withdrew that evening. John McCain, who was previously considered an underdog in the Republican race, led the pack into Super Tuesday on February 5th.

The candidates views on health insurance can be a major issue in the race.The results of the 22 state primaries held on Super Tuesday were definitive on the Republican side of the house with John McCain the front runner by a sizable margin. Subsequently Mitt Romney suspended his campaign on February 7th. Then there were two. Mike Huckabee is now calling for previous Romney supporters to back his race. The Democratic primaries clearly indicated one result – the race between Hillary Clinton and Barak Obama will be a photo finish.

February 06, 2008

Some Calif. Health Plans Use Questionable Tactics

A group of insurance brokers in California contend that health plans in that state are employing questionable tactics to stifle the marketing of “wrap-around” health reimbursement arrangements (HRAs), and steer employers instead to more profitable products. But the health plans maintain that they are within their right to prevent outside firms from administering HRAs tied to their products.

Teresa A. St. Clair, a broker with Route Three Insurance and Financial Services, based in Paso Robles, Calif., suggests that some health carriers are trying to preserve profit margins by steering small groups toward high-deductible products that have higher premiums and no HRA option. “Carriers are dealing with the loss of premium by telling agents what plan the HRA can be paired with,” St. Clair says.

At issue are policies that restrict the availability of stand-alone HRAs sold independently of a carrier’s benefit plan, generally a high-deductible product. Interest in these wrap-around HRAs is growing as self-funded small groups seek ways to rein in premiums and health care costs, sources tell ICDC.

While most carriers market qualified high-deductible health plans (HDHPs) with HSAs, some of them restrict the use of HRAs to a limited number of products. Blue Cross of California, Health Net of California, Inc. and Kaiser Permanente require self-insured companies to sign a form acknowledging that the employer will not offer its employees a wrap-around HRA except as they are available with designated products.

Blue Cross of California markets one high-deductible product with an HRA, while Kaiser offers two HRA-based products and Health Net markets one HRA product.

February 04, 2008

Schwarzenegger’s Universal Healthcare Suffers Setback

On January 28, California Gov. Arnold Schwarzenegger lost a key vote on his way to being the second Republican governor to institute universal health coverage. The bill, ABX1 1, a joint effort between the Republican Schwarzenegger and the Democrat Assembly Speaker Fabian NÃºñez, died in the senate health committee on a vote of one to seven, with three abstentions.

The four Republican senators on the committee voted “no” because the bill represented a dramatic $14.9-billion expansion in the size of government, would have instituted the largest business tax in California history and would have added to California’s growing budget deficit. Committee vice-chair, Dr. Sam Aanestad (R.-Grass Valley), an oral surgeon, said, “Extracting billions of dollars in new taxes from employers will just drive many of them out of business. We can come up with a better plan.” The bill sought to impose a payroll tax on business, along with a hospital tax and a $1.75 hike in the cigarette tax. It also extended benefits and coverage to illegal immigrants.

Democrats cited two main concerns in opposing the bill. First, it looked financially unstable, threatening to add to California’s $14.5 billion deficit, thus jeopardizing existing welfare programs. Perhaps more importantly though was that it did not go far enough in their eyes. Sen. Sheila Kuehl (D.-Los Angeles) chairs the health committee. Sen. Kuehl authored SB 840, a state single-payer plan vetoed by the governor in 2006. Kuehl voted against the measure, citing among reasons a personal mandate similar to that imposed in Massachusetts, saying, “We can’t simply say to the people of California, ‘Go buy insurance.’”

February 03, 2008

Democrats push plans for affordable health insurance

Front-runners Hillary Clinton and Barack Obama, as well as former candidate John Edwards, who dropped out Wednesday,have put forth proposals to make health coverage more accessible and affordable.

Inspired by existing health reforms in Massachusetts, their proposals would prohibit insurers from rejecting individuals or charging them higher rates because of preexisting health conditions.

But forcing insurers to cover everyone won't necessarily solve the problem. States that have so-called guaranteed-issue laws, such as New York and New Jersey, have some of the highest health-insurance rates in the U.S. That means that healthy people in those states often decide not to buy coverage until they get sick, which further boosts costs for everyone.

Guaranteed issue could work if everyone were persuaded to buy coverage, spreading the risk among more people and pushing down prices. So Clinton, Edwards and Obama have each proposed a so-called mandate requiring individuals to be covered by insurance.

For example, Clinton and Edwards would require most employers either to provide coverage for their employees or to contribute to the cost. Clinton would exempt most small employers but offer them a tax credit as an incentive to provide coverage. Obama breaks with his opponents. He would require that all children have insurance but not all adults.

February 01, 2008

California Health's Hidden Costs on Campuses

College students, already absorbing tuition bills that are rising faster than inflation, are increasingly facing hundreds and sometimes thousands of dollars in extra and unexpected health insurance costs and medical bills.

The reason: Most campus health centers have not registered as "in network" for the biggest regional health insurers. That means students covered by their family's plan typically can't get reimbursed for many tests and procedures performed by campus health clinics.

In addition, a growing number of colleges are heavily promoting school-sponsored plans, which range in price from a few hundred dollars at Brigham Young University to as much as $2,500 a year at schools such as Brown University. While some plans are generous, others offer comparatively anemic coverage to the students but healthy profits to either the insurance company or the college. And increasingly, schools are automatically charging students for the campus plan unless they provide proof of other coverage each year. A few colleges are even requiring all students—including those who are already covered—to buy school-sponsored policies. Typically, students can't shop for better deals because the colleges approve only one plan.

The conflict adds up to big bucks, since young people generally spend $2,000 to $3,000 a year on health costs, creating a market worth billions.

January 31, 2008

While Governor Schwarzenegger’s health reform plan crashed and burned this week on the legislative highway, it confirmed once again that using mandates to achieve universal coverage is a failed model for reform.

The take home lesson: America’s health insurance industry is the problem. Any reform based on a prominent role for the industry precludes success, because the private health insurance industry is simply too bureaucartic and expensive. The administrative overhead in the current private system approaches 30%.

As the members of the California Senate also learned, it is financially impossible to expand coverage to the uninsured without also controlling costs. This means taking on the politically challenging task of ousting the insurance industry profiteers.

The failure of the mandate model in the six states that have tried it can be directly attributed to the Californian insurance industry. Each of these state reform efforts promised cost savings, but none included real cost controls. As the cost of health care soared, legislators backed off from enforcing the mandates or from financing new coverage for the poor. Just last month, Massachusetts projected that its costs for subsidized coverage may run $147 million over budget.

The “mandate model” for reform rests on political surrender: avoid challenging insurance firms’ stranglehold on health care while coercing the uninsured to purchase costly insufficient insurance policies. But it is economic nonsense. The reliance on private insurers makes universal coverage un-affordable.

It is ironic that what started out as a “politically feasible” alternative to the single payer bill SB 840 that was approved by both houses and then vetoed by the Governor turned out to have little political support when it came under scrutiny in the Senate.

It failed the “politically feasible” test because its supporters surrendered to the insurance industry in advance on cost control and then gave them a blank check in the form of millions of new customers.

State budget experts testified that the bill was fatally underfunded and could leave the state billions of dollars in the red. Having been down that road with the hastily enacted energy deregulation fiasco, proponents could only muster one yes vote out of eleven committee members.

The wisdom of the California Senate’s rejection of the mandate model of reform jump starts the national movement for an entirely achievable single payer medicare for all system.

California Health-Care Reform to Shift Focus

The demise of California's attempt at comprehensive health-care reform this week means that advocates of overhauling the health-care system will turn their focus back to Washington, several experts said yesterday, as an increasingly tough budget climate raises new questions about whether states can go it alone.

When the plan championed by Gov. Arnold Schwarzenegger (R) and state Assembly Speaker Fabian Nunez (D) went down to defeat in a legislative committee, so did hopes that successful reform in such a populous, influential state would bolster efforts elsewhere to cover more of the nation's 47 million uninsured.

While California is unique in some respects -- it has a diverse electorate, a high number of uninsured and a history of occasional budget crises -- experts said some of the same economic forces at work there threaten to slow or swamp similar proposals in other states. The slumping economy diminishes states' tax revenue at the same time that spending demands increase as more people seek help from programs such as Medicaid, which serves the poor. And, unlike the federal government, state governments have to balance their budgets every year.

"The failure of California's plan pushes the focus about expanding health insurance coverage even more strongly towards Washington," said Paul B. Ginsburg of the Center for Studying Health System Change, a nonpartisan policy-research group. "I've never believed that states would be able to go very far on their own because of their fiscal limitations. A state in an average year could be able to afford something, but once they get into a recession, they get into fiscal trouble."

Karen Davis of the Commonwealth Fund, a nonprofit research institution, said federal leadership is crucial because California and some other states' plans depend, in part, on expanding Medicaid and other public insurance programs to cover uninsured children who currently do not qualify. But the Bush administration has been unwilling to sign off on most such expansions. "The lack of federal support for state innovations has proved to be a major hurdle to reform," Davis said.

January 30, 2008

Schwarzenegger to Press Universal Health Insurance

California Gov. Arnold Schwarzenegger on Tuesday vowed to continue pressing for legislation that would provide health insurance to his state's uninsured, a day after a universal health care bill he supported died in a Senate committee.

Lawmakers had missed a golden opportunity for California to show the rest of the United States how to establish universal health care, Schwarzenegger said in a speech to the press club of the state capital.

"I'm as determined as ever," Schwarzenegger said. "The issue is not going to go away."

The bill had been closely watched across the United States because of California's size -- it is the largest state in the U.S. -- and the rising anxiety among Americans about the spiralling cost and lack of availability of affordable health care.

Nearly 47 million Americans, or 16 percent of the population, were without health insurance in 2005, according to the National Coalition on Health Care.

Health care has become a major issue in the presidential campaign, with leading candidates acknowledging that changes are needed, and some advocating plans to expand coverage.

Schwarzenegger, a Republican, and state Assembly Speaker Fabian Nunez, a Democrat, brokered the bill that would have given Californians without medical insurance some level of coverage by requiring they obtain it individually, through employers or via a state program.

January 23, 2008

California health bill to mean higher business costs

Businesses in Novato and throughout California will face increased costs, and many employees will be required to buy healthcare if ABX11, the current California healthcare reform bill and its companion ballot initiative, are approved by the legislature and voters, respectively. According to several business organizations, that could mean everything from reduced hours to layoffs for small and medium companies, the majority of Novato’s business community.

The legislation, backed by Gov. Schwarzenegger and State Assemblyman Fabian Nunez, was scheduled to be heard this week in the California Senate, and a ballot funding initiative may be put before voters November of this year. If approved, by 2010 businesses will be subject to a “pay or play” system, either providing employees health insurance, or paying a variable payroll fee into a general pool for employees’ healthcare.

Coy Smith of the Chamber of Commerce said his organization had not taken an overt position on the proposal, but was in general agreement with the California chamber, CalChamber, which recently signed a joint statement with other groups opposing it.

“We don’t (take positions) sometimes on statewide bills … we’ve taken a passive position supporting the California chamber,” said Smith. “(The bill) could potentially increase insurance costs to small and medium-sized businesses, and it would have less of an effect on large businesses.”

Smith said that due to economic conditions, the timing of the measure was wrong.

“Clearly the economy is not as strong today as it was a year and a half ago. It’s not a time to be placing additional expenses or requirements on businesses,” he said. “It could potentially mean cutbacks and lay-offs and hiring freezes. It’d have a negative affect on the economy.”

Representatives of the Independent Business Alliance declined to comment on the issue, but Downtown Business Association president Denise Athas said she felt the bill would do more harm than good.

“The part that will affect small businesses are the employer fees, and if they do raise them 1 to 6.5 percent of payroll, that would be absolutely detrimental to a small business,” said Athas. “I’ve been doing a sort of a rough survey of businesses and where they are today, and all businesses are being affected by the economy. Any additional expense to the employer will put a much greater burden on them.”

That's one reason to count on Perata to try to get the Senate to pass the universal health care plan backed by Assembly Speaker Fabian Nunez, D-Oakland and Republican Gov. Arnold Schwarzenegger.

Perata's job, however, has become far more difficult now that state Sen. Leland Yee, D-Daly City, has come out against the plan. Yee's opposition, announced Tuesday, means that two Democrats on the Senate Health Committee oppose the plan.

Opposition from those two Democrats leaves the bill one vote short in the Senate Health Committee, which will hear the bill on Wednesday. Republicans uniformly oppose the bill.

All is not lost for supporters, however. Perata may ask for a courtesy vote to get the bill on the floor or he may change the make-up of the committee to assure enough votes to move the bill along.

The plan promises to provide health insurance for 3.6 million Californians. It raises taxes on employers, hospitals and tobacco, requires Californians to buy insurance and provides subsidies for low-income residents.

The measure passed the Assembly quickly last December, but has been slowed down by Perata, who is waiting for a Legislative Analyst's report to see how it would impact the state's budget, which faces a $14 billion deficit.

Besides upholding his image among Democrats, Perata also needs to pass the plan to maintain close ties to Nunez and Schwarzenegger. The two leaders have staked much of their reputations on the health plan, hoping it will be a national model.

Perata, in turn, will need their help to pass his priorities, including a water bond.

January 20, 2008

California Health Care - A Mandate for Insurance or Healthy Choices?

Not many issues are being discussed about health care in the political arena, and for good reason. Other than the costs of defending the country (war?), health care is the leading economic burden to US citizens. The direction that is being taken to manage this problem is one that deals with economics instead of individual responsibility, the latter which would save thousands of hours of debate and many more billions (now trillions!) of dollars.

While putting more attention to thwarting the overweight and obesity epidemic, we now see the media covering individuals who are taking the "easy" but dangerous road to weight loss with a disregard for a healthy lifestyle, and claiming to help lead the fight against obesity (name omitted). While a voice for the consequences of poor food and lifestyle choices would be more suitable for someone who has chosen Gastric banding surgery as a last resort for losing weight, the wrong message is sent if this same voice is meant to teach people how to get healthy.

Americans don't need more surgical procedures or diet pills to solve their weight problems - it's just a new band-aid that perpetuates a growing problem.

As reported in Time Inc, "pharmaceutical companies are hoping to improve their bottom line by shrinking their customers' bottoms." Yet the bottom line is the first objective, never mind the side effects of new types of drugs that solve nothing, just delay the inevitable - a health crisis that will force change or face death.

When will the laziness cease? When will we wake up to the fact that there is no free lunch? When will we learn that we can't just keep creating ways that seem to make our life easier, when in fact just make us lazier? Hence, the diet pill pushers. Got weight? Here's a pill. We need to get back to the basic fundamental actions for good health - water, lean protein, fruits, vegetables, whole grains, and yes...exercise!

January 19, 2008

California health-care plan will

Republican governor Arnold Schwarzenegger has teamed up with a leading California Democrat, Assembly Speaker Fabian Nuñez, to draw up and promote a $14.4 billion health-care plan that is being touted as a possible model for the rest of the country.

The California Nurses Association, among others, opposes the bill, calling it a “boondoggle” for the insurance companies.

In December, the measure passed in the state assembly by a vote of 45 to 31. It will now go before the state senate. The sponsors hope to place it on the November ballot.

About 20 percent of California residents—6.6 million—lack medical coverage. Nationally the number is about 47 million.

News articles and commentators have noted the similarity between the California plan and the health-care proposals being promoted by Democratic presidential candidates Hillary Clinton, Barack Obama, and John Edwards.

The centerpiece of all these plans is to get everyone who lacks coverage to buy medical insurance or to enroll in Medicare or some other health plan. The California measure requires that residents of the state have insurance by 2010. Supporters of the plan say it’s like the requirement that all drivers who own cars purchase auto insurance.

For at least some of those who cannot afford this plan, the California bill provides for government subsidies and tax credits. A new bureaucracy is to be created that will figure out who does and does not have a low enough income to qualify for the financial aid.

In the plans proposed by Clinton and Edwards, the purchase of insurance is mandatory, with means-tested provisions for financial help and tax breaks to those who qualify. Obama says his plan would be mandatory for children only, but he would consider making it mandatory for all under certain conditions. All these presidential candidates say they would end tax cuts passed under George Bush to help finance their plans.

January 17, 2008

Health insurance companies could split over Democratic proposals

A Gallup poll in November showed nearly two-thirds of Americans think the government should be responsible for everyone having health coverage. The parties are clearly split on the issue.

In broad strokes, the Democratic candidates support a government-legislated solution; the GOP candidates favor a private-market approach. Democratic presidential contenders may ultimately find an unlikely ally: the same big health insurance firms they fight on the campaign trail.

Nearly 1,300 health insurance companies are united under the American Healthcare Insurance Providers, a Washington, D.C.-based association. This coalition represents both large and small insurance firms. The large companies may find benefits in the Democratic proposals, while the smaller companies see only burdens.

“It seems to me that the closer we get to actual legislation, the chances are that the coalition will fracture,” said Matthew Holt, a San Francisco-based health-care advocate.

The latest test of the coalition comes in California.

For now the AHIP union remains strong. California’s largest health insurance provider, Blue Cross/Blue Shield, has strongly opposed a health-care bill launched by Gov. Arnold Schwarzenegger, in spite of the bottom-line benefits they could reap from the bill. The bill mandates that individuals purchase health insurance, but prevents health insurance companies from denying coverage based on pre-existing conditions.

“It’s essentially a deal,” Holt said. The California proposal, if approved, would provide Blue Cross/Blue Shield a wave of new clients, he said. Smaller providers, however, would likely find themselves bypassed in the rush of Californians looking for health insurance, Holt predicted.

January 16, 2008

As the State Senate prepares to consider Assembly Bill X1-1, the compromise health care reform proposal hammered out by Governor Arnold Schwarzenegger and Assembly Speaker Fabian Nunez, the state's insurance agents urged lawmakers to make the fixes that will be necessary to achieve the goal of affordable health care coverage for all Californians.

In a letter to Senate President Pro Tem Don Perata and others, the California Association of Health Underwriters (CAHU) and the National Association of Insurance and Financial Advisors-California (NAIFA-California) encouraged Senators to take the time to get the reforms right.

"The bill before the State Senate is complicated and complex," said CAHU President Neil Crosby and NAIFA-California President Dennis P. Sunderman. "Comprehensive health care reform is too important, and the stakes for Californians are too high, to push this legislation through without needed changes."

The agent organizations identified several specific changes that are needed. One is a provision in the bill that segregates Californians who receive premium assistance in the form of tax credits into a state-run health insurance purchasing pool. Crosby and Sunderman note, "The state doesn't require food stamp recipients to shop only at government-run grocery stores. Similarly, Californians receiving tax credits to help pay premiums should not be forced to shop only at a government-run health insurance store."

The agents also urged Senators to define the "minimum health coverage" all Californians must obtain. "Without a definition of the minimum benefits package it's impossible to assess the impact this bill will have on individuals, employers, taxpayers, or on the state's precarious finances," Crosby and Sunderman said.

Agents recommended Senators thoroughly review the funding mechanisms in ABX1-1. They expressed concern that the funding sources identified in the bill, specifically an employer tax on payroll, will fail to keep up with state spending obligations for health care.

November 11, 2007

Health care plan needs more work on costs

Assembly speaker Fabian Nunez and Senate President Pro Tem Don Perata have devised a new health care proposal that comes closer to the one advocated by Gov. Arnold Schwarzenegger. However, it is riddled with problems that illustrate why health care reform is such a difficult task.

The idea behind both the governor's and the Legislative leaders' plans is to extend health care insurance to most of the estimated 5 million Californians who are not covered. That is a noble goal, but one not easily achieved without considerable expense and changes in the way medical care is financed and delivered.

Perata and Nunez have moved a bit nearer the governor on health care reform, but neither plan goes far enough in reducing skyrocketing medical costs.

High and rapidly rising medical costs are the main reasons many lower- and middle-income Californians do not have health insurance, and why too many people use emergency rooms as their first choice for medical care.

On the positive side, the Nunez-Perata plan (as well as the governor's) would insure more children with comprehensive benefits.

Also, government subsidies would help low-income adults get similar coverage through the state's Health Families program.

Unfortunately, these benefits come at a considerable cost to businesses and taxpayers. Most employers would have to pay a 6.5 percent payroll tax or provide the equivalent in health benefits for their employees.

Even small businesses, many of which cannot afford to pay health benefits, would have to pay a tax of 2 percent to 4 percent of their payrolls.

But insurance companies would be able to raise monthly rates as they see fit. There would be huge subsidies for private insurers, via tax credits for families earning 250 percent to 450 percent of the federal poverty level to buy private insurance, which would not have price caps.

Nunez and Perata agreed with Schwarzenegger to make health insurance mandatory, something many Democrats and labor unions opposed because of affordability issues.

There would be an exemption from the requirement for people whose insurance costs exceed 6.5 percent of household income. Most insured families or their employers already pay more than 6.5 percent of household income for health care.

November 03, 2007

California among worst in providing health insurance through jobs

The percentage of Californians who get health insurance through their jobs is among the lowest in the country, according to a study released Thursday.

Nationwide, about 63 percent of Americans have health policies offered by their employers. But in California, only 55.7 percent of workers were covered through their jobs last year, making it the state with the fifth-lowest level of employer-sponsored coverage, according to the study by the Economic Policy Institute in Washington.

The number of employers offering health insurance has fallen nationally in recent years due to rising premiums and the diminishing bargaining power of the average worker. Companies have responded to the pressure by requiring employees to pick up a larger portion of the tab, through higher co-payments and monthly contributions, and reducing benefits and coverage for spouses and children.

In California, the problem is worse due to the sheer size of the population and the fact a large number of residents work in jobs that typically do not offer health insurance, such as agriculture, hospitality and the service industry.

According to the study, which uses data from the U.S. Census Bureau's Current Population Survey, the number of Californians covered by their jobs dropped to just under 18 million workers in 2005-2006 from 18.5 million in 2000-2001, or nearly half a million people.

While low-wage workers had the lowest level of coverage, middle-wage employees in California saw the steepest decline in those offered insurance during the past five years. And more than 600,000 fewer children in California were covered by their parents' insurance last year than in 2000.

October 29, 2007

Governor has plenty of health care critics

Since the governor released details two weeks ago of his proposal to cover all Californians - including illegal immigrants - he has been pilloried by labor and consumer groups frustrated that the substance of his Health Care Security and Cost Reduction Act has changed little in 10 months of talks.

Now those groups are expected to take center stage during an Assembly hearing on the proposal Wednesday that is expected to be a very long, very detailed dismemberment of Schwarzenegger's plan.

But even his critics hope that the meeting will, paradoxically, kick-start negotiations among the governor, Assembly Speaker Fabian Nuñez and the array of interest groups with a stake in the deal.

More than 6 million Californians are uninsured - including more than 100,000 in San Joaquin County and the Mother Lode, according to the California Health Interview Survey.

Many of those with insurance can't afford to use it due to exorbitant deductibles. Others who are insured strain under skyrocketing annual premium increases.

Massachusetts was the first state to seriously tackle the idea of universal health coverage, but its experiment is still in doubt as costs soar and low-income residents howl over being forced to pay into the system.

The state's top Democrats - Nuñez and Senate President Don Perata - had not proposed universal coverage because they said it could be too expensive. Both their plans would have greatly expanded coverage to needy Californians but would not have required everyone to buy health insurance.

October 21, 2007

House Sustains President’s Veto on Child Health

The House on Thursday upheld President Bush’s veto of a bill to provide health insurance to 10 million children, but Democrats vowed to send it back to him next month, with minor changes, in the belief that they could ultimately prevail.

Despite a multimillion-dollar advertising campaign and intense lobbying by children’s advocates, supporters of the bill were unable to convert a single House Republican who voted against the bill last month.

For now, the insurance vote stands as the latest example of how Mr. Bush can still get his way on Capitol Hill. Through artful use of veto threats and his veto pen, Mr. Bush has fended off attempts to force a change of course in Iraq — a feat Democrats would never have imagined when they pushed Republicans out of power a year ago. He has twisted Democrats into knots over domestic surveillance, and forced them to rethink a resolution condemning as genocide a century-old massacre of Armenians.

The outcome on Thursday, reminding Democrats of the limits of their power, came as Congress and the president prepared to square off over a dozen spending bills needed to finance the government in the new fiscal year. President Bush has threatened to veto at least 10 of those measures, while also holding the Democrats responsible for not acting more quickly on the bills, which were supposed to be enacted by Sept. 30.

In the vote on Thursday, the roll call was 273-156. That was 13 votes short of the two-thirds majority needed to pass the measure over the president’s objections. In the Senate, the bill was approved last month with more than a two-thirds majority.

The bill would have increased spending on the State Children’s Health Insurance Program by $35 billion, bringing the total to $60 billion over the next five years. It would have provided coverage for nearly 4 million uninsured children, while continuing coverage for 6.6 million already on the rolls.

October 18, 2007

Proposal for mandatory health insurance is a joke

Gov. Arnold Schwarzenegger wants it for California, Mitt Romney instituted it last year in his home state of Massachusetts, and it's the centerpiece of Hillary Rodham Clinton's health-care plan. The individual mandate requires people to purchase health insurance much the same way they are required to purchase car insurance. On Oct. 10, former Iowa Govs. Terry Branstad and Tom Vilsack proposed to a health commission formed by state legislators that they make individual mandate into Iowa law. This week, the commission will begin work on finding ways to enhance health care in our state, and the Branstad/Vilsack proposals will be on their list. Trying to thwart chronic diseases and keep overall costs low by preventing the need for substantial and expensive procedures are admirable goals. Doing so is especially critical in a state where more than 9 percent go uninsured, but forcing Iowans to purchase health insurance is neither the most proper or most effective way of achieving these objectives.

Unlike the decision to drive without auto insurance, living without health insurance is a decision that truly affects only the individual. Lost on our two former governors is that the uninsured only choose to live unprotected because they cannot afford to do otherwise. Most of these people would not ask their fellow citizens to pay for their health insurance, which is how the Massachusetts plan works. The creation of public subsidies allows lower-income individuals to have their insurance paid for by the rest of society and allows for some citizens to drop their current insurance in favor of having someone else foot the bill. The Massachusetts plan's flaws were evident less than a year after its inception, when authorities had to exempt 20 percent of the uninsured from tax penalties for noncompliance. The simple fact is that some people will disobey the mandate and choose to live without health insurance. Attempting to rid society of a problem by making it illegal doesn't always work, as speeders on Interstate 80 can attest.

Predictably, Branstad and Vilsack have assured us that ways to lower insurance costs will be developed and implemented should an individual mandate become law. This Editorial Board wonders how, after not doing so during a combined 24 years in office, the former governors will somehow produce these magical solutions in three months. If the concept of individual mandate continues to grow in popularity among states and even be implemented on a national level by our next president, it would be a further example of the destructively cozy relationship between the insurance industry and the government. Universal health care needs to be realized, soon, but forcing coverage is futile, irresponsible, and misguided.

October 16, 2007

BC Life & Health Insurance Company Launches Enhanced Group Life

Most people don't like thinking about life and disability insurance until they need to have it, running the risk of financial disaster. According to The Actuarial Foundation, the majority of American workers and their families are unprepared for the financial risk of disability, often going uninsured, and 64 percent of workers don't have access to long-term disability insurance coverage through their employer. And one in three workers over the age of 30 will become disabled for at least three months at some point during their careers, according to America's Health Insurance Plans. Through an arrangement with Anthem Life Insurance Company, BC Life & Health Insurance Company has launched an enhanced Group Life and Disability product portfolio for California's small and large group employers, offering flexible solutions with modular plan designs that help employers protect themselves against the high cost of disability, while providing employees valuable protection for their earnings.

Included in the customizable portfolio are basic group term life, dependent life, optional life, optional dependent life, short-term disability, voluntary short-term disability, long-term disability, voluntary long-term disability, and voluntary accident death and dismemberment. Additional member services are available through Resource Advisor, offering access to a spectrum of life and work resources, and Travel Assistant which provides a safety net for members should a medical emergency arise while they are traveling for personal or business reasons all at no additional cost.

According to LIMRA, over half of small and large group employers agree that life insurance is the most important non-medical benefit to offer employees. "People often don't like to talk about adequate life and disability benefits until they need it, running the risk of a financial disaster. These new enhancements will help employers protect their employees and their budget," said Brain A. Sassi, president and general manager, Blue Cross of California. "When life and disability products are paired with Blue Cross of California's health, pharmacy, dental, vision and EAP, we offer employers a full range of benefits and services to provide a complete employee benefits package."

These products are available as employer-paid basic benefits, basic benefits with a combination of employer and employee contributions, employee- paid voluntary benefits, or a combination of basic and voluntary benefits.

October 14, 2007

On Friday, the Foundation for Taxpayer and Consumer Rights stated that a recently implemented Massachusetts law that makes the owning of health insurance mandatory for all state citizens fails to be a healthy model for California health reform.

Under the new Massachusetts law, by April 15, 2008, all residents have to prove on their tax returns that they have purchased private health insurance or be charged with financial penalties.

A proposal modeled on the Massachusetts law was put forth on Wednesday by California Governor Schwarzenegger. The FTCR says that his proposed law fails to take into consideration the affordability crisis faced by Massachusetts residents while also including a provision of that would encourage insurance companies to raise their premiums. Under that proposal, California health insurance providers will be allowed to keep 15% of premium revenue for overhead and profit.

The FTCR points out that coverage in Massachusetts is already considerably more expensive than promised and insurers, whose premiums are not capped or regulated, have indicated that they will increase their premiums again next year.

"Insurers, who will keep 15% of premiums no matter what they pay doctors and hospitals, will be all too happy to pay more--and charge policy holders more--in order to keep more," said Jerry Flanagan of the FTCR.

Massachusetts officials have estimated that 18% of those residents currently uninsured cannot afford insurance at all , and the vast majority of new enrollees since the ostensible July 1st, 2007 deadline have needed to receive subsidies to pay for their policies.

"They will end up paying more for less health care -- an inevitable outcome when individuals are forced to purchase private health insurance and costs are not regulated. While it is beneficial to provide health care to the working poor, the Massachusetts plan is far from solving the un-affordability of private insurance for middle-income workers. The plan, with its very small employer penalties, also may encourage employers to steeply reduce or eliminate work-based coverage," said Carmen Balber of the FTCR.

October 12, 2007

California insurance commissioner pays visit to Napa

California’s second highest ranking Republican official dropped in on Napa Thursday, addressing the Napa Valley Republican Women as the group toasted its 60th birthday.

California Insurance Commissioner Steve Poizner, expected by some pundits to make a run for the Republican gubernatorial nomination when Gov. Arnold Schwarzenegger is termed out in 2010, criticized the precarious finances of the state.

“I think California is way off track,” he told Napa Republicans Thursday. “I think our economic engine is sputtering. We’ve gone from first to worst in so many categories.”

He more or less dodged a question about his political future. “I’m focusing right now on being the best insurance commissioner I can be,” said Poizner, who beat former Lt. Gov. Cruz Bustamante to win the commissioner job and has been in office for 10 months.

While most Californians may be unaware of what the insurance commissioner does, Poizner said he has been at work cracking down on insurance fraud, whether lawbreakers are found in doctors’ offices, behind the wheel of vehicles or involved in the workers’ compensation system.

Poizner treated the Napa Valley Republican Women’s luncheon like a convention speech, moving seamlessly from keeping the room in stitches to reeling off eye-popping statistics about insurance, insurance fraud and outlining his ideas for strengthening the state.

Examples include the fact that the insurance industry is a $120 billion a year business in California, representing about 15 percent of the total state economy.

Bad traffic? Poizner offers another economic eye-popper: It costs the state $20 billion a year in lost productivity.

Then there’s humor: While campaigning for insurance commissioner door-to-door in Palo Alto, he said he ran into a 12-year-old girl who pointed him out ruefully as “the capitalist.”

October 07, 2007

California's Health Care Dreams

While Obama, Clinton and Edwards trot out their plans for giving all Americans access to health insurance, a working blueprint for universal health care may be unfolding far from Capitol Hill.

The state of California--where 6.6 million people, or 19% of the population (the highest of any state), are uninsured--is wrestling with that issue right now. Earlier this month, Gov. Arnold Schwarzenegger called a special legislative session to hammer out a palatable universal health care bill. Lawmakers could draft a proposal in the next few weeks.

One deeply interested party is California's small business lobby. While small companies provide over half of America's private sector jobs, many of them can't afford to offer health benefits--which means they can't attract the talent they need to compete and grow.

The rest of the country is watching too: If passed, the bill could set the stage for policy battles in other states and Washington.

"If California demonstrates that it's possible to get something done, everyone will take notice," says Larry Levitt, a vice president with the Kaiser Foundation, a national health care research foundation.

With health care costs through the roof and climbing, no one doubts that something has to give--but who's going to pay for all that care?

Whatever plan lawmakers gin up, entrepreneurs in California will likely feel a sting in the form of stiffer taxes. The incentive for small businesses to sign on: In theory, those dollars would help make health care more affordable for potential employees, thus leveling the playing field in the struggle to hire talent away from larger competitors that can afford to offer insurance. Second-order result: A healthier population puts a smaller strain on the overall health care system (emergency rooms and so forth) and ultimately reduces overall health care costs--again, in theory.

In the past, small businesses have bristled at health care-related tax hikes. But with health care costs rising 10% or more a year, they too are starting to listen.

"There's a sense that something is going to happen," says Scott Hauge, president of Cal Insure, a health insurance firm, and president of Small Business California, a nonprofit advocacy group. "There's a pressure that wasn't there five years ago."

Two key proposals are at the center of the California debate. Both are "play-or-pay"--meaning that either small businesses offer insurance, or they pay a tax penalty.

October 01, 2007

California's Health Care Dreams

While Obama, Clinton and Edwards trot out their plans for giving all Americans access to health insurance, a working blueprint for universal health care may be unfolding far from Capitol Hill.

The state of California--where 6.6 million people, or 19% of the population (the highest of any state), are uninsured--is wrestling with that issue right now. Earlier this month, Gov. Arnold Schwarzenegger called a special legislative session to hammer out a palatable universal health care bill. Lawmakers could draft a proposal in the next few weeks.

One deeply interested party is California's small business lobby. While small companies provide over half of America's private sector jobs, many of them can't afford to offer health benefits--which means they can't attract the talent they need to compete and grow.

The rest of the country is watching too: If passed, the bill could set the stage for policy battles in other states and Washington.

"If California demonstrates that it's possible to get something done, everyone will take notice," says Larry Levitt, a vice president with the Kaiser Foundation, a national health care research foundation.

September 19, 2007

Health care becomes city's cause

As Democratic presidential candidates unveil proposals for universal or near-universal health care for all Americans, San Franciscans already are signing up for a new program that guarantees free or sliding-scale medical care to all uninsured adults.

The program provides a network of care to city residents, regardless of existing medical conditions, immigration status or ability to pay.

For Judy Rees, a 45-year-old part-time home health aide, the program, dubbed Healthy San Francisco, will coordinate treatment for her slipped discs, borderline diabetes and anxiety.

"I've never had insurance," she said as she read a Healthy San Francisco flier in the waiting room at Glide Health Services, a clinic in the impoverished Tenderloin district. "I'd never go to the doctor unless I was deadly sick."

"You never know what's going to happen," said Frederic Tarmis, 38, an uninsured bartender in the Glide waiting room who said he was eager to sign up for the program. "I try not to think about it."

Bill Henry, 63, a part-time gardener, said he'd been navigating the city's free health clinics and San Francisco General Hospital for years and wasn't sure he needed the plan. Then he added, "Once I went to General and didn't know where to ask and I ended up getting bills."

The plan began in pilot form in July. Expanding citywide this week, it is the first attempt by an American city to tackle the health-care crisis, with the assistance of state and federal funds. Unlike other universal health-care plans being proposed, Healthy San Francisco is not insurance -- because health coverage doesn't travel with the individual. Care is provided and paid for only at clinics and hospitals in San Francisco.

"What we're seeing here is the absence of real action at the federal level," said Ken Jacobs, chairman of the University of California, Berkeley, Center for Labor Research and Education. "It certainly sends the message that this is possible."

September 10, 2007

Small Calfornia Firms Struggle to Pay Health Costs

To understand why it is so hard to cover the uninsured in California, consider the case of Brookfields, a small chain of family style restaurants near the state capital.

Profits are low, and the owner, Sam Manolakas, says he cannot afford his workers' rising health care premiums. But since his waitresses, cooks and busboys earn so little, neither can they.

So, like low-wage workers across California and the nation, many of Manolakas' employees are dropping their coverage.

Now, reformers in Sacramento want to reverse this trend, which is a major reason why 6.8 million Californians had no insurance at some point last year.

Gov. Arnold Schwarzenegger says Brookfields' workers should be forced to buy health insurance on their modest wages. Democrats in the state Legislature say Manolakas should bear the burden. They are in intense negotiations to find a compromise in the waning days of the Legislative session.

But, experts say, neither approach has enough subsidies to help Manolakas and his workers afford these proposed mandates, given that medical costs are rising so much faster than inflation.

"Health care is still really expensive," said Marian Mulkey, an analyst with the California Health Care Foundation. "This is shifting the cost but not reducing the cost."

Shifting the cost, of course, is what Manolakas has been doing for years.

He says the insurance premiums for his 250 employees have been rising 10 percent to 20 percent a year, while his profit margin is 3 percent and falling. This year, it is about 1 percent.

September 09, 2007

Despite High Cost, Small Business Says It Supports Universal Health Care

In a recent poll, more than half of small-business owners in California said they are in favor of contributing to a statewide pool that would offer affordable health care insurance for their employees.

Eighty percent of those surveyed also believe that businesses should provide their employees with health care, according to the survey released Aug. 24 by Small Business for Affordable Healthcare, a coalition of the Small Business Majority, a progressive nonprofit organization based in Sausalito.

The San Diego North Chamber of Commerce conducted its own survey to gauge how the local business community felt about Gov. Arnold Schwarzenegger’s health care reform proposal in preparation for his Aug. 31 visit.

Of the 112 people surveyed, 38 percent agreed that every resident in California should have health insurance and nearly 60 percent agreed to increase Medi-Cal reimbursements to doctors and hospitals, according to a statement from Gary Powers, chief executive officer of the chamber.

Under the governor’s plan, employers who have “10 or more employees would be required to spend 4 percent of Social Security wages on health care expenditures for employees or pay an equal amount to fund a statewide purchasing pool,” according to the California Hospital Association.

“It (the chamber survey) also showed that the majority of businesses should share the responsibility,” said Kamal Muilenburg, executive director of the San Diego Business Healthcare Connection. “We support the notion of health care’s shared responsibility.”

September 06, 2007

California, not Congress, is in driver's seat on health care

The number of Americans without insurance continues to rise, but Congress likely will let states and presidential candidates take the lead on health care reform for now.

The Census Bureau reported Aug. 28 that 47 million Americans lacked health insurance in 2006, up 2.2 million from 2005. Many of these uninsured Americans work for small businesses, so these firms will play a major role in any initiative to cover more people.

The health care issue facing Congress is whether to expand a government program covering children. Both the House and Senate have voted to make more children eligible for the State Children's Health Insurance Program, but they disagree on how to pay for it.

President Bush, meanwhile, favors modest expansion of SCHIP and has threatened to veto either bill. He says the legislation would be costly and encourage people to turn to the government instead of private insurers.

Once the SCHIP battle is resolved, Congress will have little time -- and probably little appetite -- for bigger health care reforms.

"What we're hoping for is a very small incremental piece that will get us some relief for a few years," said Amanda Austin, a lobbyist for the National Federation of Independent Business.

This could take the form of health care purchasing pools for small businesses -- a longtime priority for NFIB -- or tax breaks to help small employers afford insurance, she said.

The chairman of the Senate Finance Committee, Max Baucus, D-Mont., has said that he plans to put together a small business health care package this fall. But, Austin said, "I don't know when he'll have time to do it."

All eyes are on California, not Congress, in the health care reform fight.

Republican Gov. Arnold Schwarzenegger wants to require businesses to offer health insurance if they have 10 or more employees. Otherwise, they would have to pay 4 percent of their payroll into a state fund that would cover uninsured individuals. Doctors and hospitals also would have to pay new fees to help finance coverage for the uninsured. All would be required to have insurance.

September 04, 2007

Children’s Health Coverage Seen at Risk

At a time when several states and both houses in Congress are pushing to expand a children’s health-insurance program partially financed by the federal government, the Bush administration’s new guidelines restricting enrollment have drawn criticism from school officials and health advocates, who warn that children will lose access to insured medical care.

The $25 billion-a-year State Children's Health Insurance Program, or SCHIP, is intended for children in families that earn too much to be eligible for Medicaid but may find it hard to afford private health insurance.

The U.S. Department of Health and Human Services, in an Aug. 17 letter, told states that they cannot enroll children from higher-income families—those with income above 250 percent of the federal poverty line—unless the states can prove that 95 percent of their poorest children are already covered through Medicaid or SCHIP.

Though the letter is described as clarifying existing regulations, some state officials see it as new policy and an attempt to circumvent the efforts by states and Congress to expand the program. The 95 percent enrollment target for the state’s poorest children is impossible to meet, they contend.

As a result, many children will remain uninsured, school health officials argue—and that could affect schools by weakening student preparedness for learning and increasing the need for services.

“The more kids that are covered, the more kids are likely to come to school without chronic health-care problems and ready to learn,” said Bruce Hunter, the associate executive director for public policy for the Arlington, Va.-based American Association of School Administrators, whose organization supports the congressional proposals to expand SCHIP coverage.

Without insurance of their own, many families also come to rely on schools for services, said Donna Mazyck, the president of the National Association of School Nurses, based in Silver Spring, Md. “School nurses are sometimes the only health-care provider a student regularly sees,” she said. “We definitely see the importance of students’ having a regular primary- care provider.”

August 30, 2007

Number of Americans without health insurance climbs

The number of Americans without health insurance rose last year from 44.8 million, or 15.3% of the population, to 47 million, or 15.8%, the Census Bureau reported today.

In a report on income, poverty and health insurance coverage, the bureau also said that the median household income -- the income level of Americans at dead center of the U.S. economy -- rose seven-tenths of one point to $48,201 last year, mainly because more people were working full time.

Analysts said the figures showed that the nation was still a long way from making it back to where it was before the last recession in 2001, and helped explain why working Americans were more pessimistic than the overall economic numbers might suggest they should be.

"The only people who have recovered their position from the previous expansion are those near the top of the income distribution. The rest of Americans are still waiting to recover the ground they lost," said Gary Burtless, a senior economist with the Brookings Institution in Washington.

Median household income peaked in 1999 at $49,244, then fell for five years before climbing back in 2005 and last year. But the improvement was not the product of higher earnings but more work. Real median earnings of men and women who worked full time declined in 2006. For men, the decline was 1.1%, to $42,300; for women it was 1.2%, to $32,500.

The nation's official poverty rate experienced its first significant decline of this decade, from 12.6% in 2005 to 12.3% last year.

Most of the problem with health insurance were traceable to the continued erosion of employer-based healthcare coverage. The percentage of people covered by employer plans decreased to 59.7% of the population in 2006, down from 60.2% in 2005.

August 28, 2007

One-fifth of Californians lack health insurance, report says

A record number of Californians - an estimated 6.7 million adults and children that account for nearly one in five of the state's residents - went without health care insurance last year, according to new figures released today by the U.S. Census Bureau.

Nationwide, about 47 million Americans lack health coverage, including 8.7 million children - also record numbers, the report said.

The estimates are part of an annual analysis of poverty and health care in the United States, which also showed that median household income nationwide rose seven-tenths of one point in 2006 to $48,201 - still below the peak of $49,244 reached in 1999.

Many public policy experts and elected officials were especially concerned about the health care data, especially for children because the number of uninsured kids grew for the second year in a row.

"The trend I've been seeing is the growing number of children in middle class families who lack coverage," said Jim Keddy, director of PICO California, part of a national coalition of faith-based community groups that advocates for the poor.

"As health care costs go up, more and more families are either not being offered health insurance through work or what they are offered costs too much."

The new Census estimates show that about 816,000 children in California lack health care - which means that most of them receive medical services at hospital emergency rooms and community clinics.

After months of talking about the issue, Gov. Arnold Schwarzenegger and legislative leaders are increasingly focused on ideas for extending coverage to more Californians who lack insurance.

The governor has proposed a plan aimed at covering all Californians without health insurance by having workers, employers and care providers share the cost of expanded coverage. He would also mandate that residents have insurance.

Democratic leaders have proposed a plan that would cover only working families that now lack coverage, with the lion's share of the costs being paid by employers.

Another plan pending before the Legislature would create a single-payer program where all residents are covered under a plan managed by the state and funded through taxes.

August 25, 2007

Insurance group reaches out to underserved areas

A major insurance group said it will distribute $25 million in grant money to improve health care in medically underserved areas of California such as the San Joaquin Valley.

Health clinics, hospitals and community organizations can apply to UnitedHealth Group and its subsidiary PacifiCare for grants ranging from $100,000 to $5 million. The program grew out of regulatory approvals for UnitedHealth Group's acquisition of PacifiCare in 2005. The $8.1 billion acquisition created a larger health insurance group serving about 70 million people nationwide.

Grants will be awarded over the next three years for technology improvements, medical education, efforts to prevent chronic disease, telemedicine and coordinated care initiatives. Last year, UnitedHealth awarded a $5 million grant for developing a medical school at the University of California at Merced.

"We would encourage organizations in Stanislaus and neighboring counties to apply for these funds," said Tyler Mason, a spokesman for UnitedHealthcare, a division of UnitedHealth Group. "These dollars are available to improve access to health care by using technology and education."

The program has given money to telemedicine projects for improving prenatal care in rural areas, Mason said. Another area of interest is coordination of care for patients who are discharged from hospitals to skilled nursing facilities. Often, the nursing facility isn't close to the hospital and patients don't receive the follow-up care they need, Mason said.

The UnitedHealth Group grants also are intended to address physician shortages predicted in a 2005 University of California study. That study said the southern part of the Central Valley is prone to shortages of health care workers.

August 22, 2007

Health Insurers Target the Individual Market

Health insurers are targeting the two groups of people least likely to be covered by insurance at work -- young people in their 20s and 30s, and early retirees who don't yet qualify for Medicare.

Companies including Aetna Inc. and WellPoint Inc. have recently begun offering individual health-insurance packages tailored for young adults, the fastest-growing population of uninsured Americans. Besides basic medical coverage, the packages also often include such benefits as teeth whitening and gym-membership discounts, because insurers say many young people are especially concerned about looking good. But to keep the policies affordable -- Humana Inc. packages start at $26 a month, for example -- the plans usually have high deductibles of as much as thousands of dollars a year and strip out some coverage that could be important, such as maternity care and brand-name prescription drugs.

Meanwhile, Humana also recently began marketing policies for the second-fastest-growing group of the uninsured, early retirees -- ages 50 to 64 -- who because of buyouts and company cutbacks in retirement benefits are increasingly caught in the gap between stopping work and Medicare eligibility. Aetna, WellPoint and other companies say they also plan to roll out packages for older adults in coming months.

Eric Wolfson, a 32-year-old independent filmmaker in Los Angeles, says his mother bought him a policy from Blue Cross of California, a WellPoint subsidiary, because she was worried about his not having health insurance. Because of the high deductible, however, he recently had to pay $1,700 out of his own pocket to cover hospital emergency-room costs after separating his shoulder during a martial-arts workout. Still, Mr. Wolfson says he likes having the insurance policy in case anything catastrophic happens. "It's protection for the big stuff," he says.

August 20, 2007

Kaiser Permanente HMO CEO backs Calif health reform

The chief executive of the biggest health maintenance organization in the United States said on Thursday he backs key elements of California Gov. Arnold Schwarzenegger's proposal to extend health-care coverage to millions of uninsured individuals.

Schwarzenegger's $12 billion pitch to provide health insurance in the estimated 6.5 million without insurance in the most populous U.S. state would seek higher taxes from doctors and hospitals and asks health plans to limit profits.

The Republican governor's plan is not seen passing this year because of a limited time schedule will make it difficult to pass a budget as well as resistance from state lawmakers, but it has a chance of re-emerging when the Legislature returns in January.

"I think it's attainable and achievable," George Halvorson, the CEO of Kaiser Permanente, the biggest HMO in the U.S., with more than 8 million customers, said in an interview. "I'd like to see universal coverage passed in California, and I'd like to see it be a model (for national reform)."

The California plan follows a spate of efforts by states to cover the rising numbers of individuals in the U.S. lacking health insurance, now estimated at 45 million people, or 15 percent of the population.

Halvorson said he backs Schwarzenegger's proposal to require that individuals have insurance, and to mandate that employers offer it, or pay into a fund. He also said he supports a requirement that health plans not reject coverage based on preexisting medical conditions.

For health plans, a controversial element of Schwarzenegger's plan is a proposal that would require health plans to spend at least 85 cents of every dollars in premiums on medical care, according to Wall Street analysts.

August 17, 2007

The key to health care affordability - everybody pays

Imagine if people were able to game the Social Security system, never paying in a single dime, but able to jump in right before retirement and pick up checks. That would be unfair. The costs for those Americans who responsibly pay their fair share would increase because they would be subsidizing those who don't. Eventually, the system would collapse.

Fortunately, the system protects all of us by requiring nearly everyone to participate in Social Security. As a result, every American has a secure pension for their retirement, regardless of how much they earned in their career.

In California, Gov. Arnold Schwarzenegger has proposed the same model for a state health-care system. His plan obligates everyone to obtain health coverage, and makes that coverage available by requiring insurers to accept all comers even if they have been sick and couldn't obtain insurance before. Those who can't afford coverage would be subsidized.

As the first health plan in the country to endorse universal coverage, Blue Shield has long understood that achieving insurance coverage for all requires responsibility to be shared by all. Everyone can qualify for coverage regardless of their health history only if everyone has an obligation to buy it.

Some have suggested that it's acceptable to require health plans to cover everyone without requiring that everyone have coverage. Like that freeloader who would enroll in Social Security only when he can cash out, individuals under that arrangement could buy health insurance only when they face expensive medical costs. The only way to offset those costs would be significantly higher premium rates for those who are paying their fair share. Not only does requiring participation make health care more affordable because costs are shared equitably. It also enables everyone to receive preventive care and early medical treatment for conditions before they get worse - and more expensive to treat.

August 13, 2007

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July 09, 2007

Medical expenses can shatter security

Retirement for Ellen Warwick isn't shaping up as she had planned. Warwick, 62, and her husband, 72, quit their jobs in California three years ago and moved to Noblesville. They thought they'd travel when they weren't spending time with their two grandchildren in Indiana.

Instead, they allocate much of their money to health care.
"We do travel some," Warwick said. "But I had dreams and thoughts about going to Europe and traveling around the world, but we have to be careful.

Health-care expenses may stand in the way of a carefree retirement for many baby boomers, too. More than half of the people surveyed for The Star's poll cited coping with the rising cost of health care as a major worry for how they will weather retirement.
There's no secret to the best way to handle this dilemma. As with other areas of retirement planning, the answer, experts say, is to save, save, save.

The average 65-year-old couple retiring this year will need about $215,000 to cover medical costs, according to Fidelity Investments.
People should not expect Medicare to meet all their needs. Studies show that in the last two years of life, people spend an average of $11,000 out of pocket, said Susan Chen, an assistant professor of health economics at Purdue University.

July 03, 2007

Health insurer cited in policy cancellations

BC Life & Health revoked 1,880 individual health insurance policies in California in 2004 and 2005, and a state agency that examined a sampling says it found that more than half the cases it reviewed were improperly handled.

The Department of Insurance said it studied 83 sample cases and issued citations in 49 of them, alleging 67 violations of fair-claims handling laws.

In one case, the department contended that BC Life, a Blue Cross company, told a policyholder in a letter that it rescinded coverage because of an undisclosed medical condition, even though the condition was clearly stated on the individual's application.

In another case, the department alleged that BC Life improperly rescinded a policy after miscalculating the period of time between treatment and the effective date of coverage. BC Life declined to reinstate coverage even after the department brought the error to its attention, according to a report issued by the agency.

When coverage is rescinded, it is as if the policy never existed, leaving the policyholder and healthcare providers to settle outstanding charges.

The 67 citations could lead to fines of as much as $10,000 per sustained infraction, as well as follow-up examinations.

The report was posted on the department's website last week with little fanfare, even though it had been highly anticipated by consumer advocates and lawyers for policyholders who were suing BC Life and other insurers, challenging the rescissions as unfair and illegal.

The Department of Insurance launched an investigation last year when John Garamendi, now lieutenant governor, was the commissioner. The report marks one of the first occasions on which Insurance Commissioner Steve Poizner, who took office in January, has publicly weighed in on a health insurance issue.

June 26, 2007

The number of American adults without health insurance has jumped by 2 million, according to the U.S. Centers for Disease Control and Prevention. Almost 44 million Americans — equal to the combined population of 24 states — are listed as uninsured in 2006, a 6 percent jump from the previous year.

There are few things that Gov. Edward G. Rendell and I agree on. The fact that they have too many residents without health insurance coverage is one of them. Between 750,000 and 900,000 adults are uninsured. They are part of the growing tide of working men and women who do not have health coverage.

Rendell's answer for the uninsured is predictable: Raise somebody's taxes and get the government more involved in running health insurance programs.

"More taxes, more government involvement" is the liberal mantra for whatever ails us when it comes to folks like Ed Rendell and Hillary Clinton. The key ingredient in Rendell's "Prescription for Pennsylvania" is to impose a tax on employers who don't provide health coverage for workers.

The problem with raising taxes on employers is that it will force some of them out of business because they can't afford to insure workers. That will put more workers in the ranks of the uninsured. Tax-and-spend liberals like Rendell never think through their knee-jerk "solutions" to problems.

Inexplicably, Rendell waited until his fifth year in office before addressing the problem of uninsured workers. Didn't these people need health coverage in the first four years of Rendell's tenure?

Rendell has been unwilling so far to address other factors that contribute to the uninsured such as malpractice rates, insurance fraud, bureaucratic waste and tort reform. Rendell's Insurance Department might as well be a PR/Marketing wing for the big insurance lobby. (Didn't Rendell's insurance secretary just take a job with the insurance industry?). Instead of looking out for consumers, Rendell's Insurance Department has been a little too cozy with big insurance and has looked the other way while insurance companies have raised their rates astronomically.

And nobody has been able to provide a satisfactory explanation of how non-profit insurance carriers in the state are sitting on billions of dollars in profits. Sounds to me that the Blues are charging way too much for premiums and not paying out enough in claims.

And unlike Dr. Rendell's prescription for solving the health insurance problem (getting government more involved in medicine), the Wonderling and Schroder bills would not cost taxpayers a thing.

June 24, 2007

Women and health care

As California moves toward adopting the most comprehensive health-care reform in the nation, the needs of half the state's population -- women -- must be taken into account.

A range of obstacles -- economic, social and logistical -- make it difficult for women to gain access to a full range of health services.

As the debate proceeds, lawmakers should remind themselves that women are the major consumers of health care -- because of their reproductive needs and because they live longer, with higher rates of chronic illness than men.

It's an uncomfortable truth that the wages of women still lag considerably behind men. The median income for women in California is about $37,000 -- compared to $45,000 for men. In fact, two-thirds of the 2.5 million uninsured women in California are from low-income backgrounds.

The ability of women and their families just to afford health coverage -- at a time of rising costs -- is one of the main issues that must be addressed in any health reform plan devised in Sacramento.

For health-care "reform" to be meaningful for most women in California, premiums need to be affordable. Women will need protection from high out-of-pocket costs from co-pays and deductibles. On average, high deductible health plans are 25 percent less than for traditional plans. But these plans often demand unaffordable out-of-pocket payments for routine events, such as having a baby.

Women are also at greater risk of losing health insurance. One in 5 women in California receives health coverage as a "dependent" through her husband's employment. That coverage is threatened when women are widowed, get divorced -- or when their spouses lose their jobs.

June 20, 2007

ABC Demands ‘Answers’ on U.S. Health Insurance

On Monday’s "Good Morning America," the ABC program shifted into full advocacy mode as anchor Chris Cuomo investigated the health insurance industry. A week after the network promoted Michael Moore’s new documentary "Sicko" for over 21 minutes, co-host Diane Sawyer announced that, regarding health care, the program was demanding "some answers" with a new segment. According to Sawyer, the series is "for you, for all of us." At the close of the report, the ABC anchor even pleaded with the audience for examples of nefarious health care companies:

Diane Sawyer: "...If you have an insurance company policy, a question that you want to raise, you want us to tackle something that you think the insurance companies are doing, you write to us. You let us know about it. ABCNews.com. We are on the case."

And while Cuomo was "on the case" of a woman who had difficulty getting her insurance company to approve a much needed eye surgery, there has been no similar look at Canadian horror stories where government run health care made one woman with breast cancer wait three months for radiation treatment.

A report by the Canadian Fraser Institute found that the average wait time in that country to see a general practitioner was 17.7 weeks. One such incident found a woman waiting over three months to receive radiation therapy for breast cancer:

A similar lawsuit was filed in Quebec on behalf of 10,000 women with breast cancer who were forced into long waits for radiation therapy. Anahit Cilinger was one such patient. After having a lymph node removed in October 1999, she was put on a waiting list for radiation therapy. Three months later and with no end to the waiting in sight, she traveled to her native Turkey and paid $12,000 for the treatment.

June 18, 2007

California Health Insurance Coverage Is Becoming Less Affordable

For many Californians in the individual and small-group markets, sky-rocketing healthcare costs mean benefit drop-offs or spiking premiums, a new study says.

Some healthcare reform advocates -- including President Bush -- have suggested moving all Americans out of employer-based health insurance and into plans purchased on the individual market, arguing that more choices for consumers will lead to lower premiums.

In California, individual insurance premiums do seem to be increasing at a slower rate than small-group market premiums, according to the study appearing Thursday on the Web site of the journal Health Affairs.

But the trade-off for lower premiums is steep reductions in benefits, the study found.

Between 2003 and 2006, premiums for employees of small businesses rose 53 percent from $250 to $382, while premiums in the individual market increased only 23 percent to $259.

However, individual-market policies paid 75 percent of medical costs on average in 2003 but only 55 percent in 2006. In contrast, small-group policies retained their actuarial value, paying for roughly 83 percent of medical expenses across the period.

What's more, individual-market enrollees faced much higher cost-sharing in 2006 than their small-group-market counterparts. The average deductible in the individual market was $2,136, more than six times the size of the average small-group-market deductible of $348.

June 15, 2007

Graduates’ next exam: insurance

While Heather McManus crammed for her last batch of college finals this week, she was also studying her health insurance options.

McManus turned 22 on Wednesday and joined the ranks of the 6.5 million uninsured Californians because she no longer qualified for her parents’ health coverage.

“It’s like, ‘Happy Birthday, now you have no health insurance,’ ” said the Cal Poly senior, who will graduate Saturday.

McManus falls in the age group most likely to be uninsured: young adults. About one-third of Californians between ages 19 and 29 are uninsured, according to the California Health Interview Survey.

The high cost of health insurance adds pressure to new college graduates looking for jobs. Two of every five college graduates will become uninsured in the year after leaving school, according to the Commonwealth Fund, a nonpartisan think tank.

McManus, of Livermore, never thought much about health insurance. She always had her parents’ coverage, and during college, she received care at the Cal Poly student health center. After Saturday, both safety nets will be gone.

About 100 million insurance customers in the U.S. have access to Web-based tools, but companies don't have an estimate of how widely they are used. Insurers hope to at least double the technology's reach by the end of next year.

Aetna chief executive Ronald Williams says the change is as revolutionary to health care as the introduction of the ATM card was to banking in the 1980s.

But privacy advocates say there's no guarantee the records will be safe from hackers. Some worry patients may refuse to disclose some illnesses to their doctors to keep documents out of databases.

"As a former nurse, I know that back in the 1980s, patients who were alcoholics did not want to have paper records," said Sue Blevins, president of the Institute for Health Freedom "They just didn't want people to know & That could affect the quality of their care."

Aetna, which offers personal health records to its customers, says security procedures include a member login and an online registration Web site with secure sign-ons. In addition, customers can restrict elements of their records from being shared among health practitioners.

Aetna said personal health records are protected by the same security technology that is used for online banking.

Personal health records, which are available through insurers Aetna, Blue Cross Blue Shield and others, are intended to help doctors and patients track medications and treatments.

The technology allows doctors to record test results, immunizations, prescriptions and other medical information into an online database that can be accessed by patients, the insurer and other physicians if needed. Patients can also add details about over-the-counter medications, plans of care, family health histories and other information.

June 09, 2007

Health Insurance Companies Easing Burden of High COBRA Costs

Senate Health Committee Chairman, Senator Kemp Hannon, announced a part of the recently adopted a new budget, which enables health insurance companies to carry individuals under their parent's policy to age 25, instead of age 19 for those who do not go to college and 23 for those who do.

The part of the bill, announced at a University Student Center during a June 1 press conference, will be a relief to many parents and young people facing extremely high COBRA costs when their child reaches the age of ineligibility under their plan, but is either still in school or searching for employment. The legislation also assists those young 20-somethings who are bearing the brunt of their own health insurance costs by enabling them to obtain health insurance coverage through their parents.

June 08, 2007

Kaiser Permanente Healthcare Insurance

Health insurance is an issue and need for everyone. There are, for people who can afford them, many choices. For those without resources, the choices are far more limited but, under some circumstances, a good plan may be available to impoverished people through various 'partnerships' with public agencies. No matter what your circumstances, choices need to be discovered, examined and evaluated - good decisions for you and your family need be made. This review is a summary of one of the more comprehensive choices now available in a number of states including California (where it began), Hawaii, Oregon, Ohio, Colorado and several others, Kaiser Permanente. My family and I have been a Kaiser patients ourselves for well over thirty years, our child and grandchildren were born there, my wife and I have had surgeries, gotten eyeglasses, multiple procedures and prescriptions as functions of our membership and I have actually been employed as a Provider with them (a Clinical Social Worker in Psychiatry) for the past seven years, so I have experienced this system of services both as a consumer as well as someone on the 'inside', a care provider. These comments reflect my aggregate understanding of Kaiser, it's values and drawbacks, who it works well for and who it doesn't and it's merits relative to other insurance choices. Should you find yourself in that seminally important choice making that important decision, it is my hope that this brief discourse will be of some help to you.

Firstly, on the notion if "Integration" of services.
Kaiser is described as being fully integrated. That means that any specialist you might need to see or any medically related service you might need - everything from an inoculation, to an outpatient visit to Emergency care, a routine check up with your own doctor (Kaiser refers to this person as your Primary Care Physician), intensive inpatient treatments or even surgeries, occupational and physical therapies are all provided by Kaiser staff who have access to each other's information and, consequently, fewer errors are apt to occur as they relate to poor communication between a number of private doctors. There are a few exceptions - for example, Kaiser does not maintain it's own Psychiatry or inpatient chemical dependency program beds, but contracts for them with local specialized hospitals and programs - but, by-in-large, your medical needs will be me by Kaiser staff and ordinarily at one location! The outpatient clinicians are where the hospitals (Medical Centers) are. It is convenient in this way.

Is Kaiser cheaper than other coverages?
No, it is not. Years ago, it marketed itself as being an economical health care system. No more. Now it markets itself as being the 'best' available health care system. However, even so, a range of plans are now available that offer everything from fully priced, all inclusive plans with minor co-pays and no deductibles to less expensive plans geared to the healthier among us which cost a lot less but require more payment upfront when used. This customization of plans is available both to employers who buy it for groups or to individuals seeking to self insure themselves and their families. You can select a plan that makes the most sense for you.

June 07, 2007

Shopping for health care

When Scott Fowler quit his job at Wal-Mart to make a living as a painting contractor, he left his medical insurance behind. He and his wife went without health coverage for years because they believed they couldn't afford premiums of $600 to $700 a month.

But in recent years the health insurance industry, after so long seeming indifferent to individual customers, has increasingly catered to them, said Gary Lauer, chief executive of EHealth, which operates an online insurance agency.

Dozens of new kinds of products -- including high-deductible coverage, policies with linked sav ings accounts and policies that limit coverage for prescription drugs or maternity care -- have been introduced, said David Olsen, senior vice president of insurer HealthNet.

That has resulted in a vibrant market with a greater number of affordable options, experts say.

That proved to be a lifesaver for Fowler, who again went shopping for health coverage after his dad died of heart failure three years ago. This time, he was able to se cure a good policy for about half the price of the quotes he had received years earlier.

A few months after the policy began, Fowler was diagnosed with the same heart problem that killed his father. He spent eight days in the hospital to fix the condition. Had he not been insured, Fowler says, he wouldn't have received the life-saving diagnosis because he never would have gone to the doctor in the first place.

"It was a real blessing," said Fowler, 38, who lives in California. "When I wasn't feeling well, I realized I had insurance, so I could go to the doctor. I can't even imagine how much that insurance policy saved me."

June 05, 2007

High deductibles a pain for some insured

When Nancy Warrington became pregnant five years ago, she quit her job to become a full-time mom. With that, she lost the family's employer-subsidized health benefits.

Shopping for individual health insurance on their own, Warrington and her husband, Todd, settled on a plan with a $2,500 annual deductible and a $335 monthly premium.

"We were just looking for something [with a premium] we could afford," said Warrington, 35. "The high deductible didn't even dawn on me."

The insurance was a mixed blessing. Although it covered Nancy's appendicitis, Todd's back injury and an assortment of other medical needs over the years, the annual deductible also saddled the San Diego couple with more than $10,000 in debt.

Their case illustrates a problem with high-deductible health plans, a fast-growing type of coverage now held by about 10 million people in the U.S. The plans, with annual deductibles of $1,000 or higher and monthly premiums that can be less than $100, are a good fit for relatively healthy people with some financial means, most experts agree. The median annual income of those using high-deductible plans is about $75,000, according to a recent federal report.

The plans also are popular with young people who don't expect to run up significant medical bills.

Although the lower premiums make the plans attractive, cash-strapped families like the Warringtons run the risk of being unable to afford the deductibles, critics of the plans say.

Such consumers might forgo needed medical treatments to avoid running up out-of-pocket bills — possibly threatening their physical well-being, critics say. For these and other reasons, such plans are far from a desirable solution for the nation's approximately 47 million uninsured, they say.

June 03, 2007

Health insurance regulation proposed

A bill authored by Assemblyman Dave Jones, D-Sacramento, would require state regulators to approve increases in premiums, co-payments and deductibles proposed by insurers.

Gov. Arnold Schwarzenegger's health care reform proposal would require all Californians to obtain health insurance. As part of the governor's plan to control the costs of coverage, insurers would have to spend at least 85 percent of all premium dollars on medical care.

But a number of consumer and labor groups say the governor's plan doesn't go far enough to control costs. Californians who do not receive coverage through an employer or qualify for government subsidies would be required to purchase individual insurance. Rates for such coverage have been far outpacing inflation for years.

Jones' bill faces stiff opposition from the insurance industry. It needs enough votes to move out of the Assembly Appropriations Committee to stay alive.

"This is the big showdown," said Jerry Flanagan, health care advocate for the Foundation for Taxpayer and Consumer Rights, a consumer group supporting the bill. "The insurers want to kill it ... because the cost savings are huge for California consumers and they don't want that fact to be public."

May 31, 2007

It's No Myth: Health Coverage Matters

In the debate over health care reform the desire to boil complex issues down to pithy statements can sometimes lead to over-simplification.

That's why CalHealthReform created a series of Myths & Facts summarizing key research about important issues related to health care coverage and financing. Two new Myths & Facts, which explore the questions of access to care for the uninsured and whether preventive care saves money, are now available.

* Does coverage matter or can the uninsured already access the care they need? Federal law requires emergency rooms to treat patients regardless of their insurance status or ability to pay. Do the uninsured get needed care, and how do their health outcomes compare to those who have health coverage? Research shows that having health coverage makes a big difference.

* Will investing in prevention reduce overall health spending? The five major health reform proposals in California feature preventive care as a cost containment strategy. But the devil is in the details. While investing in preventive measures sometimes can yield health benefits, it can increase costs and must be used strategically to achieve savings.

May 30, 2007

Blue Cross of California, the state's largest health insurer, has launched a media campaign opposing health care proposals by Gov. Arnold Schwarzenegger (R) and other state lawmakers that would require insurers to sell policies to all residents, regardless of health status, the San Francisco Chronicle reports. The newspaper and television advertisements are part of an initial $2 million outreach campaign by the insurer's political committee, the Coalition for Responsible Healthcare Reform. Blue Cross is the only member of the coalition.

The ads criticize "guaranteed issue" provisions included in health care proposals by Schwarzenegger, state Senate President Pro Tempore Don Perata (D) and Assembly Speaker Fabian Nuñez (D). The ads say such plans could have "unintended consequences." Blue Cross supports the creation of a pool for residents who have health conditions that make them more expensive to cover. Ann-Louise Kuhns, a vice president of Blue Cross of California, said, "We're very supportive of health care reform efforts," adding, "We just need to fix what's broken and not break what's working."

Blue Shield of California spokesperson Tom Epstein said the insurer would not join the Blue Cross coalition. Blue Shield, which is a member of the coalition Together for Health Care, supports guaranteed issue and a requirement that all state residents obtain health coverage to balance the risk pool. Coalition members also include the insurers Health Net and Kaiser Permanente, as well as Service Employees International Union, AARP and the California Medical Association.

May 29, 2007

Insuring children helps a life

Its is unfortunate that your parents failed you and that other parents continue to fail their children. I don't intend to be mean, but the truth of the matter is it was up to your parents to provide for you and buy you glasses; not me (I am the "somebody" who gets the bill for such services).

My children, like most American kids, already enjoy free health care, free dental care, free school lunches, free breakfasts, and free cloths. My kids are also lucky enough to have a free first car, free gas, free entertainment, free internet, free cell phones, and a free college education (all things nobody ever gave me). Now of course while all of that is "free" to them, is very expensive for me; just as those things are expensive for all of those other parents providing for their children.

Reading your OpEd I was led to wonder; if your parents could not afford to buy you glasses, then how did you afford college? I presume you received Cal Grants (Free Money) because of your austere background. While your education may have been "free" for you, it was not for me.

You are still young and still learning. As you enter the work force you will come to appreciate that there is no such thing as "free". Free simply means someone else is sacrificing for you. As you get to know your co-workers you will find that most of us did not receive college educations (free or otherwise), free insurance, or free anything else. Somebody has to pay for those free programs and more often than not, the programs you advocate have to be paid for by those of us who will never qualify to take advantage of them.

I notice you are planning on becoming a nurse. With your child development degree, I presume you want to become a pediatric nurse. Understanding this, your argument becomes self serving. Ensuring children have free access to your services ensures you have a ready payer for the services you intend to offer. Last year, my daughter asked if she should take the E.R. doctor's advice and see a specialist after she fractured her jaw in a fall. Inasmuch as her fracture was "clean" and I saw no benefit from seeing another doctor, I said no. She replied, "But it's free; the insurance will pay for it." Hmmm, I've created a monster.

Then there is of course the socialist incrementalism of your argument. I believe it was Stalin who said, "The hand that rocks the cradle rules the world." Since most Americans are opposed to socialized medicine, those in support of such an entitlement system are now after the next generation of Americans - children. If you condition children to expect "free" health insurance, when they become adults they will not think twice about voting in favor of such programs. Once such an entitlement program is in place only a revolution will dismantle it.

And then there is the inability of our politicians to control our borders or our courts to control their generosity. Anyone who steps foot on American soil is "entitled" to social services, including health care. Anyone who can make it to the U.S., by whatever means, will get free health care for their children. So in effect, you are advocating free health care for every child in the world who can make it to a U.S. doctor. And of course by free, you mean I should be forced to pay for it.

May 28, 2007

Big health insurance push by coalition

Abandoning the business lobby's traditional resistance to health care reform, a new coalition of 36 major companies began a political campaign Monday calling for medical insurance to be expanded to everyone along the lines Gov. Arnold Schwarzenegger is proposing for California.

Founded by Steve Burd, chairman of the Safeway grocery chain and an ally of the governor, the coalition could boost efforts in Sacramento and Washington to overhaul health care laws. It also formalizes a growing division over the issue among businesses.

The coalition includes some of the nation's largest companies: PepsiCo, General Mills, PG&E, Wrigley, Kroger, and a number of Safeway vendors and grocery-item manufacturers such as Bumble Bee Seafoods. It also includes insurers and drug companies that probably would benefit from mandated health insurance: Aetna, Blue Shield of California, Cigna HealthCare, Lilly and PacifiCare.

Such large companies already provide medical coverage to their employees and have become increasingly frustrated as premiums have increased over the years. That has made them more willing to look to the government for solutions.

But small and midsize operations, such as restaurants and retail stores that usually don't provide coverage, have resisted wholesale changes to health care laws. California's Chamber of Commerce and the state's restaurant association led the successful ballot fight in 2004 to repeal a state law requiring companies with more than 50 workers to provide insurance.

May 14, 2007

Assembly speaker tells of reform plans as people in Fresno air their ideas.

Pete Estrada buys health insurance for employees of his Clovis printing business and backs proposals to have other employers do so, too.

"I'm already providing my share," Estrada said. "I think that if everybody were on an even playing field, the system would work much better."

That's why Estrada lent his support to Assembly Bill 8, a universal health-care plan backed by Assembly Speaker Fabián Núñez, during a town hall meeting Saturday on a patio at the downtown Community Regional Medical Center.

Núñez's bill has plenty of competition in this year's Legislature, with his Senate counterpart, Don Perata, D-Oakland, carrying another bill and Gov. Schwarzenegger pitching his own proposal. But all share the same broad goal -- extending coverage to the state's estimated 6.5 million uninsured.

"Within five years, everybody in California would have health care -- that's the plan that I'm proposing in a nutshell," Núñez said. "We believe that this is the year we will get this done."

Still, halfway through the current session, prospects remain iffy. Many Republicans oppose employer mandates, a key element of most proposals. Some on the other side support Senate Bill 840, a plan by Sen. Sheila Kuehl, D-Santa Monica, to replace private insurance with tax-funded, government-managed health care.

May 11, 2007

California's Health Insurance Plans statement on health care

"Health insurance plans remain committed to a safer, more effective and interconnected health care system. Our health plans have demonstrated that they have a unique role to play in achieving these objectives.

"We support the four cornerstones advanced by the Secretary and are implementing specific strategies to coordinate care, empower consumers with information, and maximize the quality and safety of care provided.

"As an industry, we have advanced specific recommendations to achieve an evidence-based system and cover all Americans. In addition, we have forged critical alliances to create a uniform quality measurement system and advance interoperability by working together with consumer and provider organizations.

"We will continue to collaborate with key stakeholder groups to contribute ideas and expertise to create a safer, more effective, and interconnected health care system."

May 09, 2007

Competition good for health-care industry

Choice and competition work in health care. Unfortunately, most of us aren't lucky enough to have access to a market driven and shaped by them. This year employer health-care costs have risen 7.7 percent, according to a Kaiser Family Foundation survey, more than twice the rate of inflation or workers' wage growth. This is lower than it's been in recent years (costs rose almost 14 percent in 2003). But health costs are still high - and likely will go even higher next year.

Some of your fellow citizens are luckier. This month, millions of federal workers and retirees, including members of Congress, get to pick and choose their health plans for 2007. According to the Office of Personnel Management, which runs the civil service, their insurance premiums will rise, on average, just 1.8 percent. About 63 percent of them will see no premium hike at all.

These Americans are enrolled in the Federal Employee Health Benefits Program (FEHBP), a consumer-driven system in which many different carriers offer a choice of 284 private plans nationwide. FEHBP plans include a variety of benefit packages, including health-savings accounts. The bottom line: Feds get high-quality care at competitive prices. No wonder they're highly satisfied.

The FEHBP isn't the only example where intense competition works. Another, paradoxically, is Medicare. The overall cost of the new Medicare drug benefit is a serious problem, but at least drugs are being delivered to seniors through competitive private health plans. The result: lower drug prices. When the drug benefit was enacted, the projected average monthly premium was $37.

Now, intense competition among competing plans has brought this under $24 per month, nearly a 40 percent reduction, accompanied by growing patient satisfaction. That's what choice and competition can deliver.

May 02, 2007

Study: 1 In 4 Kids Go Without Health Care

Some uninsured children of the working poor don't go to the doctor's office; it comes to them.

They make too much for Medicaid but not enough to have their own insurance.

And 150,000 patients per year, nationwide, get free care from 21 mobile units provided by the Children's Health Fund. But a new report out Thursday from this non-profit group says far too many kids are falling into a huge health care crevice, CBS News has learned exclusively.

The group's report finds despite billions of dollars in government spending, more than one in four children still don't have full-time health care — a gap twice as big as anyone thought.

"It's more than just insurance and lack of insurance, that are keeping children from getting medical care," says Dr. Irwin Redlener, president of the Children's Health Fund of Columbia University.

It's estimated that 9 million children are completely uninsured. But the new study says 11.5 million more kids end up without medical care for part of the year. And another 3 million can't get a ride to the doctor. That's more than 23 million children.

April 30, 2007

Pre-existing conditions should not disqualify health insurance

Each individual possesses genetic markers and medical technology has advanced to the level that the human genome can be mapped to specifically predict a person's predisposition to disease.

An unborn child can be tested by a trained physician to determine susceptibility to certain diseases - such as cancer, diabetes or Alzheimer's - decades before they're diagnosed. This information can lead to early treatment and perhaps even cures, but the fear that it could be used to deny people health insurance and employment opportunities accompanies it.

That trepidation is one step closer to being calmed with the U.S. House passage of HR 493 - the Genetic Information Nondiscrimination Act. The Senate is expected to follow suit making it illegal for health insurance companies to deny people coverage because of their genetic make-up and for employers refusing to hire people for that same reason.

While I want to shout "Hooray" and celebrate the legislation that basically tells these companies it is none of their business as to what health condition a person could likely develop, it does nothing to solve the discrimination occurring now with "pre-existing conditions."

My 2-year-old son was diagnosed with a tectal plate brain tumor, located at the brain stem, that caused hydrocephalus when he was 8 months old. It was determined by his pediatric neurosurgeon to be congenital. Fortunately, my husband and I were able to insure him the day he was born from an employee contribution plan through my spouse's employer. This plan covers our entire family. Thinking ahead, we decided to look into acquiring affordable health insurance for our son after my husband's retirement, which is in about 10 years. Guess what? No one will insure our little guy because he has a "pre-existing condition."

The option we were told repeatedly by insurance companies, which would be a sure way to get our son insured, was to become destitute, liquidating all our assets, to qualify for governmental assistance through Medicaid. It was offensive every time to be told discreetly in all its political correctness that the health care system does not encourage people to be productive.

Quite the contrary, even though knowledge and treatment are leading to better health for people with conditions like my son - which were less than 20 years ago debilitating and deadly - because an innate ailment is possessed, those people are automatically disqualified from insurance that would help provide health care services and medications that could prolong life and even enable those people to be positive contributors to society.

April 28, 2007

Group begins health insurance study

A task force studying health care coverage in the state will find out first who doesn’t have medical insurance and why.

A polling firm will update studies on uninsured South Dakotans done in 2001 and 2004, said Kevin Forsch, a governor’s staff member who is coordinating the project.

The goal, Forsch said, is to answer the questions, “Who are the uninsured? Why are they uninsured? How long have they been uninsured?”

A 2001 study concluded that 8.1 percent of South Dakota residents lacked insurance. A 2004 update put the figure at 8.5 percent.

The so-called Zaniya Task Force was created by the 2007 Legislature after bills died that would have required health care coverage for all residents. Many lawmakers and Gov. Mike Rounds said that was premature without current data on the number of people without insurance and the reasons they lack coverage.

April 25, 2007

What is a PPO or Point of Provider Oganization

A Preferred Provider Organization is a form of managed care closest to an indemnity plan. A PPO negotiates arrangements with doctors, hospitals and other providers who accept lower fees from the insurer for their services. As a result, your cost-sharing will be lower than if you go outside the network of providers.

If you go to a doctor within the PPO network, you will pay a copayment (a set amount you pay for certain services -- say $20 for a doctor or $10 insurer may reimburse you for 90 percent of the cost if you go to a provider within the network. If you choose to go a provider out of the network, the insurer might only reimburse you for, say, 70 percent of the cost.

In addition, with an out-of-network provider, you must pay the difference between what the provider charges and what the plan pays.

Another characteristic of PPOs is the ability to make self-referrals. In essence, plan members can refer themselves to doctors of their choice, including specialists, inside and outside the network. However, as described above, plan members may incur additional charges for using out-of-network providers.

April 23, 2007

Health care is a business...or should be

Ultimately all health care is paid for by business activity. Business provides the wages, the return on investment, the insurance, the taxes that pay directly for health care, and the insurance and taxes that fund government programs. When the government manages to provide services at all, it can give you nothing that it does not take from you or others, or from your employer and other employers. The total added value the government creates for your benefit is nothing.

The government now uses your money to pay for 50 percent of health care. That is up from less than 10 percent, forty years ago. The increase in health care costs that has accompanied this process is largely caused by government...the actual origin of the "health care crisis," discovered and proclaimed by Richard Nixon and Edward Kennedy in 1971. Their proposed solution was more government. They got it.

The "crisis" was created by government, not just through its own reckless spending, but through the consequent destruction of much of the free market.

In a free market, if you did not have much to spend on insurance premiums, you could buy a policy that simply covers you for a major illness or a severe injury. Many people worry about the financial ruin that might result from such misfortune and want coverage only for that. They are willing to take their own risk for routine medical expenses if they have reasonable coverage for emergencies.

Such policies are often forbidden by state governments. In California, for example, such policies are not available. Legislators and regulators have imposed 49 specific coverage requirements on all insurance companies. Many states have such requirements. It does not matter if you do not want coverage for chiropractic, or in vitro fertilization, or electronic shock or hypnotherapy for mental illness...you may still have to pay for it. That is, providers in the insurance business are not allowed to offer a policy that you might want and that they would like to offer...they are forbidden. If those restrictions drive the cost of insurance up to more than you can pay, you can thank the government. Insurance policies will get even more expensive in California if the recent proposal of the Governor to require coverage of such "wellness" care as gym and Weight Watcher memberships becomes law.

There are those in the insurance business in other states who could help you with a policy that meets your needs at a cost you can afford. But they cannot, because policies from out-of-state providers are outlawed by your state government. When bills were proposed in Congress to allow for a national market for health insurance, insurance commissioners and other state officials around the country rallied in opposition, because consumers in each state would lose the protection of their state's regulations. It appears that state officials are horrified at that thought of leaving the citizens of their own states to the tender mercy of the regulators in other states.

But relief is on the way. Massachusetts passed a law that you must buy insurance with these expensive regulatory burdens or pay a fine. Isn't that helpful? California now wants to do the same thing and also wants all physicians and hospitals to pay a new tax...not on net income but on gross revenues. That will increase their billings and your insurance premiums further. But who cares?...you would have to buy the insurance, and imposing coverage on everyone is all that matters.

April 20, 2007

Health Insurance: Women have trouble affording care needed

As Cover the Uninsured Week approaches, a new Commonwealth Fund report by researchers at the National Women’s Law Center finds that even women with health insurance coverage are more likely than insured men to go without needed health care because of costs. Also, a higher percentage of women than men struggle with medical bills.

The report, Women and Health Coverage: The Affordability Gap, by Elizabeth M. Patchias and Judith G. Waxman of the National Women’s Law Center finds that women are at a disadvantage because they have greater health care needs and lower incomes than men. More specifically, the report finds that 38% of women are struggling with medical bills compared with 29% of men. And, the high cost of health care services and premiums is forcing many women, even women with health insurance, to go without needed care. In fact, 33% of insured women and 68% of uninsured women don’t get the health care they need because they can’t afford it. In contrast, 23% of insured and 49% of uninsured men are avoiding care because of cost. Further, 16% of women are underinsured, meaning they have high out-of-pocket costs compared to their income, while only 9% of men are underinsured.

"Women are more likely than men to go without needed health care services because of costs, yet they still have higher out-of-pocket expenses. This disparity exists for both insured and uninsured women," said Waxman, vice president for Health and Reproductive Rights at the National Women’s Law Center. "As policymakers and advocates explore how to expand and improve health coverage, they should ensure that any proposal provides comprehensive benefits and low cost-sharing."

Other factors contribute to this gender gap in health care coverage and access: women are slightly more likely than men to purchase coverage in the individual insurance market which is often more expensive and less comprehensive than employer coverage. Women are also more likely than men to take prescription drugs.

"These findings show that comprehensive health care coverage that doesn’t require high out-of-pocket costs is vital to ensuring that women get the care they need to be healthy," said Sara Collins, assistant vice president for the Program on the Future of Health Insurance at The Commonwealth Fund. "As policymakers consider health care reform initiatives, they should consider plan designs that will result in meaningful, affordable, and equitable access to health care for everyone."

April 18, 2007

What is an HMO?

This is a broad term that, in general, refers to any organized plan other than a traditional health insurance company that provides for your health care. Some plans are very tightly structured so that all care is provided by the HMO's employees in the HMO's hospitals or clinics, while other plans are cooperative agreements among independent doctors, hospitals and other health care providers.

July 25, 2006

What to look for in a Health Insurance Policy

As a consumer, it is your right and responsibility to review what a plan includes to ensure it meets your individual needs and lifestyle.

California residents who are in the market for health insurance make sure they are aware of what they are buying before they make a purchase. If a consumer is buying a plan through their employer or as an individual, they should always be aware of what is covered under the plan and what is. They should have a good estimation of what would happen to them financially in the event of various scenarios such as a chronic illness requiring long-term care or a catastrophic accident. This can be done by making sure you are familiar with the plan’s deductible, covered services, and out-of-pocket limits.

California health insurance consumers should also make sure they are aware of the types of preventive care covered under their plan. For example, at what age does the plan cover a mammogram for women? At what age does it cover a prostrate specific antigen test for men? Does the plan offer a website where you can find information about health conditions and symptoms? What types of prenatal care are offered? Does the plan offer coverage for vision benefits such as visits to the eye doctor, or for dental services?

Other questions to ask include: Does the plan offer prescription drug coverage, and if so does this coverage help pay for birth control pills? What doctors and providers are part of the plan? What will happen if you receive services out of network?

Does the plan offer support services such as counseling, drug and alcohol rehabilitative services, or an 800 number for assistance with personal issues? What types of treatment – for example, homeopathic - are excluded by the plan?

Knowing beforehand what to expect for their health insurance plan can help California health insurance consumers make the best choices.

January 29, 2006

Using the Internet to find Health Insurance

How can the Internet aide you in your search to find the health insurance plan best suited to your personal situation and finances?

Health insurance is an important issue no matter who you are. California residents who need to purchase individual health insurance, make a decision about the types of health plans offered by their employer or by a potential employer, or decide what type of insurance to offer their employees may be confused about the options available. Everyone wants to make the best choice and get the coverage they need at a price that is best value for their dollar.

The Internet offers many ways to help with the process. Consumers can use online business directories to search for companies that offer what they are looking for. They can consult the web pages of various insurance companies and in some cases even apply and receive a quote online.

California is a large state with a variety of different health insurance companies serving the needs of its residents. For a new business owner selecting medical benefit options for their employees, it is particularly important to make the right decision. Potential employees in today’s competitive employment market are looking for a health insurance package that is attractive and backed by a reputable company they are familiar with.

Using the Internet to search for health insurance company rankings, third-party reviews, newspaper articles, industry data and other sources can help California residents arm themselves with as much information as possible when making choices about their health insurance coverage. While the Internet can be a valuable tool, it is important to keep in mind that credibility of the source. Be wary of marketing sites in disguise and always be certain that you know what organization is responsible for the content of any website you consult.

August 07, 2005

COBRA and Cal-COBRA

Unemployment has its drawbacks but with COBRAB and CAL-COBRA being uninsured does not need to be one of them.

COBRA (Consolidated Omnibus Budget Reconciliation Act) is designed to provide a safety net for people who might find themselves uninsured after a change in their employment status. For example, a father and husband who works as a construction foreman is laid off from his job.

In the past, the only option for this family would be expensive individual health insurance – assuming they are healthy enough to qualify. However, under COBRA, many companies are obliged to offer ex-employees the right to continue their coverage for a limited time.

There are some important things to keep in mind when considering if COBRA applies to your situation and how it will impact your budget. Not all employees are required to offer continuing coverage under COBRA – those who are not include businesses with fewer than 20 employees. There are also certain other exclusions. However, California residents have the additional protection of Cal-COBRA, which eliminates most of these exclusions, and also offers a time extension for those whose COBRA eligibility has expired.

California healthcare consumers can go to their local library, check with their company’s human resources department or visit online websites to get more information.

Once you have determined if you are eligible for COBRA, you need to consider the cost. Most employers pay for a portion of their employees’ health insurance premium costs as part of their benefits package. However, that contribution will not continue once employment is terminated. If the employee wishes to continue their health insurance benefits, they need to pay the whole amount of the premium out of their own pocket. Using COBRA to continue existing insurance is, however, generally less expensive and easier than purchasing individual coverage.

May 15, 2005

Individual Insurance Options

Individuals rights within the state of California are important items to consider when one is in need of coverage or between health insurance policies.

When California residents find themselves in need of individual health insurance, they may not know what to do or what options are open to them. For someone whose COBRA (Consolidated Omnibus Budget Reconciliation Act) benefits are about to run out, this is a scary situation. Individual health insurance can be a tough market, but Californians do have options open to them – they just need to make the choice that best fits their needs.

First, consumers should know that they will likely be subjected to a much more careful examination of their health than is usually the case with group health insurance plans. In some parts of the country, ff you are determined to have a serious condition (or even the propensity to develop a condition) such as, for example, rheumatoid arthritis, you may be rejected by the insurance company, or offered only a policy that excludes coverage for the condition in question. Exclusion riders are not allowed in California. However, another way companies deal with pre-existing conditions is by charging higher premiums.

Also be warned that some insurance companies will attempt to give the impression that you as an individual will be part of a group plan, when in actuality you are participating in what is known as a "group discretionary trust". This can result in premiums being raised without warning if you become ill. Because it might be difficult to find other coverage with a pre-existing condition, if premiums rise beyond their ability to pay consumers can find themselves in a no-win situation.

So, like anyone in the individual insurance market, California residents need to carefully research any plan they are considering purchasing, and make sure they are doing business with a reputable company that stands behind its products and is up-front about its dealings.

January 18, 2005

Getting the most from your Health Insurance Plan

Though it is essential that Californians have health insurance, it is equally or more vital that they understand their policies so they may fully utilize the coverage to which they are entitled.

All California residents should be aware by now of how important it is to have health insurance. But once you have obtained the right coverage for you and your loved ones, how do you make the most of it? Below are some suggestions on how to get the best value for your healthcare dollar.

First, no matter what type of plan you are a part of, make sure to have a doctor you can trust, and one with whom you feel comfortable interacting. Your insurance company’s website can be a great resource for selecting a provider who is right for you. For example, choosing the right obstetrician is a big part of having a happy, healthy pregnancy. Find out as much as you can about the doctor – how long have they been in practice? What is their attitude about pain relief during labor? Will they, personally, be there for your entire pregnancy, labor and delivery, or are there others doctors with whom they "share" patients?

Once you are comfortable with your choice of a provider, take a moment to ask yourself what you expect from the visit. Make a list of symptoms and concerns you want to address. Ask the doctor if he or she recommends any tests for people of your age, background and/or health history. Many insurance plans cover routine tests such as cholesterol checks.

Take advantage of your health insurance provider’s website to research any health issues that are impacting your life. You can often find online support groups, heart healthy diet tips, and treatment options. Using all the resources your health insurance offers will make you a better informed, and thriftier, healthcare consumer.

January 07, 2005

Dangers of Being Uninsured

Unforeseen accident and illnesses can financially and, possibly, physically rob one who does not have proper health insurance of an enjoyable future.

California residents sometimes find themselves, on either a temporary or a long-term basis, without health insurance. For example, each year ambitious Californians aspire to work for themselves by starting their own business. Many professions, from acting to freelancing, offer exciting opportunities for those who want to use their talents and educations to make their dreams come true. But unfortunately along with the excitement of an interesting career can come a problem – no access to group health insurance.

However, going without coverage is not the answer. Being uninsured is a dangerous situation for any individual, regardless of their age, health, or other circumstance. For example, in the space of just one morning between the hours of 10:30 am and 12:30 pm, the Los Angeles Communication Center reported thirteen traffic accidents.

Those unlucky enough to be involved in these accidents might have been in perfect health when they woke up earlier that morning, but that fact was no defense against being injured in a traffic collision that occurred out of nowhere. Without insurance, being injured in any kind of accident can be financially devastating for you and your family.

Allowing health insurance to lapse can also be dangerous if you are diagnosed with or treated for a disease or condition while without coverage. Under HIPAA (the Health Insurance Portability and Accountability Act of 1996), a person has a pre-existing condition if they have been diagnosed with or treated for a condition at any time during the six months prior to the date their new insurance would begin. If you have a pre-existing condition and have been without coverage for an extended period, you may be rejected by some health insurance companies.

December 27, 2004

Different Types of Health Insurance Plans

Traditional health insurance
Up until about 30 years ago, most people had traditional indemnity coverage. These days, it's often known as "fee-for-service." Indemnity plans are a bit like auto insurance: you pay a certain amount of your medical expenses up front -- in the form of a deductible -- and afterward the insurance company pays the majority of the bill.

Advances in modern medicine increased the cost of providing health care and made it possible for people to live longer. Those advances caused many insurance companies to look for ways to reduce their costs of doing business, giving managed care the boost it enjoys today.

Fee-for-service
For years, indemnity or fee-for-service coverage was the norm. Under this type of health coverage, you have complete autonomy when it comes to choosing doctors, hospitals and other health care providers. You can refer yourself to any specialist without getting permission, and the insurance company doesn't get to decide whether the visit was necessary.

You don't, however, have complete autonomy. Most fee-for-service medicine is managed to a certain extent. For instance, if you're not already incapacitated, you may need to get clearance for a visit to the emergency room.

On the down side, fee-for-service plans usually involve more out-of-pocket expenses. Often there is a deductible, usually of about $200, before the insurance company starts paying. Once you've paid the deductible, the insurer will kick in about 80 percent of any doctor bills. You may have to pay up front and then submit the bill for reimbursement, or your provider may bill your insurer directly.

Under fee-for-service plans, insurers will usually only pay for "reasonable and customary" medical expenses, taking into account what other practitioners in the area charge for similar services. If your doctor happens to charge more than what the insurance company considers "reasonable and customary," you'll probably have to make up the difference yourself.

Traditionally, preventive care services like annual check-ups and pelvic exams haven't been covered under fee-for-service plans. But as the evidence mounts that preventive care can prevent more costly illnesses down the road, some insurers are including them.

Fee-for-service plans often include a ceiling for out-of-pocket expenses, after which the insurance company will pay 100 percent of any costs. Needless to say, the ceiling is usually pretty high.

In a nutshell, fee-for-service coverage offers flexibility in exchange for higher out-of-pocket expenses, more paperwork and higher premiums.

Managed care
Managed care has been around in one form or another since the 1930s, but it really took off in the last 10 years. As it grew, it evolved, leaving us with three basic types of managed care plans. Today, the majority of people with private health insurance have some type of managed care.

Although there are important differences among the different types of managed care plans, there are some similarities. All managed care plans involve an arrangement between the insurer and a selected network of health care providers, and they offer policyholders significant financial incentives to use the providers in that network. There are usually explicit standards for selecting providers and a formal procedure to assure quality care.

Preferred Provider Organizations (PPOs)
One step over the managed care border is the Preferred Provider Organization. PPOs have made arrangements for lower fees with a network of health care providers. PPOs give their policyholders a financial incentive to stay within that network.

For example, a visit to an in-network doctor might mean you'd have a $10 co-pay. If you wanted see an out-of-network doctor, you'd have to pay the entire bill up front and then submit the bill to your insurance company for an 80 percent reimbursement. In addition, you might have to pay a deductible if you choose to go outside the network, or pay the difference between what the in-network and out-of-network doctors charge.

With a PPO, you can refer yourself to a specialist without getting approval and, as long as it's an in-network provider, enjoy the same co-pay. Staying within the network means less money coming out of your pocket and less paperwork. Preventive care services may not be covered under a PPO.

Exclusive Provider Organizations (EPO)
Exclusive Provider Organizations are PPOs that look like HMOs. EPOs raise the financial stakes for staying in the network. If you choose a provider outside the network, you're responsible for the entire cost of the visit.

Point-of-Service (POS)
Point-of-service plans are similar to PPOs, but they introduce the gatekeeper, or Primary Care Physician. You'll need to choose your PCP from among the plan's network of doctors.

As with the PPO, you can choose to go out of network and still get some kind of coverage. In order to get a referral to a specialist, though, you usually must go through your PCP. You can still choose to refer yourself, but it'll mean more hassles and more money coming out of your pocket.

If your PCP refers you to a doctor who is out of the network, the plan should pick up most of the cost. But if you refer yourself out, then you'll probably have to deal with more paperwork and a smaller reimbursement. You may also have to pay a deductible if you go outside the network.

POS plans may also cover more preventive care services, and may even offer health improvement programs like workshops on nutrition and smoking cessation, and discounts at health clubs.

Health Maintenance Organizations (HMOs)
Most of the time, when you talk about HMOs, you're really talking about closed-panel HMOs -- the least expensive, but least flexible type of health plan. They also tend to be geared more toward members of group plans than individuals.

In exchange for a low co-payment (or sometimes no co-pay at all), low premiums and minimal paperwork, an HMO requires that you only see its doctors, and that you get a referral from your primary care physician before you see a specialist. If you can still pick up the phone, you'll probably need to get clearance before you can visit the emergency room.

An HMO may have central medical offices or clinics (such as those used by Kaiser Permanente), or it may consist of a network of individual practices. In general, you must see HMO-approved physicians or pay the entire cost of the visit yourself. HMOs have the best reputation for covering preventive care services and health improvement programs.

December 20, 2004

Health Insurance Regulations and Issues in California

Diversity is a good thing except when it divides people or causes unforeseen disadvantages to certain minority groups.

California is a very diverse place. According to the United States Census Bureau, the state is made up of many difference races, with groups including Caucasian, African-American, Pacific Islander, Hispanic and Asian, as well as people of mixed race and those of Native American origin. California is a wonderful example of the diversity that makes America what it is – a beautiful place people of all backgrounds can feel comfortable calling home.

There are numerous benefits to diversity, both culturally and colorfully. When it comes to health insurance and health care, though, language and cultural differences can be a barrier. If something important is misunderstood, a big problem can result. For example, a young Hispanic woman who needs care for her asthmatic son might not be able to properly communicate his symptoms and health history to the emergency room physician. An elderly Asian man with diabetes might have trouble understanding his doctor’s instructions on how to manage his condition.

These scenarios are not only troubling, but likely, when you consider that according the Census Bureau there are well over 7 million Americans who speak English "not well" or "not at all". Many states, including California, are concerned about the effect this has on the quality of healthcare available to these individuals.

In response, the California Managed Risk Medical Insurance Board has put in place a program that makes sure that those covered under the state’s health insurance program, Healthy Families, have access to the services of an interpreter when receiving health care. Additionally, the program provides other assistance for those who are at risk of having cultural or language differences impair their access to quality care.

December 13, 2004

Uninsured vs. Insured in California

Within the Golden State that is California, all is not necessarily golden in terms of who does and does not have health insurance.

California is one of the most populous states in the nation. According to the United States Census Bureau, it is home to well over 30 million people of all racial and ethnic backgrounds. But regardless of their age or the language they speak each of them has one thing in common – they all need health insurance.

Being uninsured leads to higher healthcare costs in the long run because conditions and problems that could be easily cured or arrested with early detection often go undiagnosed because people can’t afford to visit their doctor.

The Kaiser Family Foundation reports that there are around 6,448,540 uninsured Californians – that is over 15 percent of the state’s total population. Of those who are insured, the Foundation reports that over 2 million require individual health insurance because they are not eligible for coverage through their employer or through Medicaid or Medicare.

Even the over 8 million Californians who do qualify for Medicaid or Medicare often require supplemental coverage. Many insurance companies offer programs specifically designed to meet the requirements of people who want or need more coverage than Medicaid or Medicare provides. For example, a senior might be interested in a program that includes discounts on services such as vision check-ups and corrective lenses, dental care or even chiropractic services.

December 06, 2004

Health Status of Californians

Where does the State of California rank in terms of its residents embodying the stereotypical picture of sunny California healthy living?

Of the fifty states, California is ranked 22nd by the United Health 2003 State Health Rankings. Many Californians enjoy good health, and the state has a low incidence of smoking when compared to other states. However, the state does less well when it comes to controlling other risk factors such as violent crime and infectious disease. It is not surprising that a populous state such as California faces challenges in these areas.

Unfortunately, not all demographic groups in California enjoy the same access to healthcare. Prenatal care, for example, is a key part of making sure that babies have the best chance possible to be born healthy. Moms-to-be are advised to visit the doctor often during each stage of their pregnancy so that their health, and that of their baby, can be monitored and the necessary tests, such as a gestational diabetes screening, can be administered.

Even those who are only considering a pregnancy can benefit by talking to their doctor first. Getting a head start on pregnancy by quitting smoking, improving nutrition and taking the recommended prenatal vitamins as prescribed by your doctor can make a big difference.

However, among expectant American Indian mothers, only around 68 percent have access to prenatal care. This is a startling disparity when compared with the over 80 percent of Asian and white women who are able to obtain necessary prenatal medical services. Regardless of their demographic background, women without health insurance are much less likely to receive prenatal care than are insured women. California and all the states should work to make sure lack of health insurance doesn’t keep pregnant women from getting the care they need to have a healthy baby.

December 01, 2004

Shopping for Health Insurance in California

For the first real entry to this blog, we're going to briefly discuss what you should be looking for when purchasing health insurance in California. The points discussed below are not exclusive to California residents only, and can be used by any American when purchasing Health Insurance.

Deciding which health insurance plan to purchase is not a universal decision, but rather a highly personal one involving considerations such as benefits and budgetary constraints.

Shopping for health insurance is a challenging process for any consumer. Since California is made up of so many diverse individuals with many different ways of life, it is important for all Californians to know what factors to consider when shopping for the health insurance that is right for their situation.

Whether you are a young person with a new job who has not been working long enough to qualify for benefits, a family man with several children whose employer does not offer insurance, a college student who is no longer eligible for coverage under their parents’ plan or a senior whose Medicare benefits are inadequate, or a self-employed individual, making sure you get the right coverage at the right price is very important. However, there is so much to consider it can be intimidating.

Before you begin looking for insurance, have a plan in place. Decide what type of coverage you need by asking yourself questions like:

How often do both myself and my dependents need health services?

Do I or a family member have a pre-diagnosed condition that might preclude qualifying for some insurance plans?

Am I or a family member planning on becoming pregnant during the time this plan will be in affect? (Many individual plans do not cover prenatal or preventive care.)

How much can I afford to pay out-of-pocket for deductibles or services that are not covered?

Once you have thoroughly considered these issues, move on to your budget and decide how much you can realistically afford to pay for coverage. Remember, individual health insurance can be expensive; however, with the proper research and preparation, consumers can find the plan that is right for them.